LTC vs. Rehab Patients: Who Is Priority?

[SilverBells, BSN]

During this COVID pandemic, my roles in my facility have switched constantly.  Prior to COVID, I was a unit manager for a rehab unit.  Once COVID hit, they designated me to manage the COVID unit until we no longer received referrals.   During this time, there were not enough patients to fill up two rehab units, so they moved me down to the LTC unit along with the rehab unit HUC.    

Now, we are receiving more rehab referrals so my old unit is opening back up again (although we are currently only accepting 50% capacity).  Because we started taking more acute patients again, I naturally thought that they would want me to return to my old unit and that the LTC unit would be split between me and my co-manager again.   However, this week I found out that this isn't necessarily the case.  First,  I am still expected to manage the entire LTC unit in addition to my new rehab patients.  Second, I found out that they didn't necessarily want me to return to working in my office on my old unit.  Apparently, the intention was that the HUC would return to the rehab unit and I would stay down on the LTC unit, none of which was communicated to me.  

The problem is, the rehab patients are more acute than the LTC patients so, in my opinion, my priority should be staying closer to them in order to keep better tabs on their medical management.  They also have many more assessments/follow ups/doctor visits than the residents on the LTC unit do and it is hard to keep up with any of this if I'm down on the LTC unit.  The rehab patients have more wounds/skin issues that I need to keep track of as well. 

 Probably, they were hoping that I would remain as a second nurse/staff member/resource person on the LTC unit, but really, the only help they need down there mostly involves feeding and toileting people and possibly helping with medication administration.   If I am expected to be managing the care of acute rehab patients, it doesn't really make much sense to designate me to assist with feeding residents, some of whom take over 45 minutes to eat and often only consume 25-50% of their meals.   In my opinion, the answer is to ensure that the unit is staffed appropriately with CNAs who can assist with those tasks and not to assume that I would be available to do that while also maintaining responsibility for the growing number of acute patients that are coming in.   

In the very least, one of the concerns the HUCs have is that with the growing number of patients being admitted, there is not enough time for them to complete scanning or uploading of documents into the resident's medical records.  I have repeatedly offered to assist with this, as all they would need to do is show me how to use the scanner, but that never seems to happen either.  I figured if they really wanted me to stay on the LTC unit, that would give me something to do.  

Anyway, are my concerns valid? Would you prioritize acute patients over LTC patients (simply because the first group requires more medical attention)? 

[JBMmom, MSN, NP]

I don't really think that prioritizing is the best description, every patient is just as important as the others, whether they are there for long term care or short term rehabilitation. 

It sounds like your office is staying in one place, but how much time to do spend in an office during your shift? Are you not expected to be on the floor? Is there a nurses station where you would be doing the work and charting? Are you the sole nurse responsible for the care of these patients or are you overseeing a charge nurse on each floor? If it's the latter, then your seating arrangement shouldn't really change your job, you can be a resource for both floors from either location, I would think. 

[SilverBells, BSN]

The amount of time I spend in my office varies, depending on how many doctor visits there are to complete, how many acute needs there are to follow up on, or whether or not there are Care Conferences or other meetings to attend.  It also depends on how many orders need following up on, lab results to review, discharges to plan, etc.  There have been times that it has taken me hours to clarify orders for a patient.  For example, one time it took me three hours to get a seizure medication for a patient and another time, it took 6 hours to get oxygen orders for someone who was discharging.   Certainly, on those days, I would not have had time to spend 45 minutes feeding any patient.  Of course, if absolutely needed, I can help work the floor, but in relation to some of my other duties, that should be  rare.  It almost seems as if they are taking advantage of me being there rather than working on the real issue, which is that there are not enough staff.   Working in the office also ensures that I can complete some of these duties in a timely manner, whereas being down on the LTC delays my completion of work since I would constantly be distracted by wandering patients, etc.  If there are any acute issues going on on the LTC unit, I can certainly and always do assist, but I'm just not sure that depending on me to be an additional floor staff member, in addition to managing the care of the rehab patients, is the right answer either.  

[SilverBells, BSN]

I know they're struggling in the staffing department and probably not addressing the issue the way that they should be because I had to call the staffing department 5 times the other day because they had no assigned floor nurses for the evening.  The first four times they either weren't aware of the issue or said, "Well, I don't really know."  Finally, I had to ask them what exactly their plan was because I wasn't getting any answers.  Frankly, I think they were hoping I wouldn't notice or speak up,  in which case I would have no choice but to replace the day nurse at the end of their shift.  

Anyway, I bring this up because it doesn't seem like their priorities are right.  I would think staffing would be a large priority.   I would also think a patient with a brand new pacemaker, wound treatments, or IV antibiotics would require extensive nursing monitoring/assessment/follow up which can't be done if nurses are constantly being pulled to feed patients who take a long time to eat.  If I had nothing else to do, it would be fine,  but rarely is there ever anything on the LTC unit that truly requires my undivided attention.  

[SilverBells, BSN]

I do have to wonder if a job change may be in my future. Lately,  it just seems as if my priorities and those of other staff don't seem to align.  I remember explaining that I was over on the rehab side because we were short and the patients were requiring a lot of attention.  They seemed to understand but at the same time mentioned that the LTC side had also been short.  I guess I don't really understand the high priority for the LTC side when those patients aren't as sick.  The kind of help they need over there also doesn't take full advantage of the skills I excel at.  If anything, they should have kept the HUC over there if they really wanted another body.  

 

I don't know....in nursing school we are taught to prioritize by need and and sicker patients need more monitoring, which would be the rehab side.  Just don't get it

[amoLucia]

I don't think you see the bigger picture here. It was said by someone in another post that maybe Admin DOESN'T really WANT you as a UM any longer. I believe that might be the bottom-line truth here.

You were slowly being downgraded into positions that you really didn't 't feel were worthy of your skillset. You complain, you don't freely pitch in to help, you cherry pick tasks. And you continue to do so even when others here have tried to enlighten you. But still you rebuff their observations.

I don't understand your thinking ----

[Hannahbanana, BSN, MSN]

If you really want an answer, recognizing that it might turn out to be one you don’t want to hear, ask for a sit-down with your manager(s) and ask them to help you understand their priorities for patient care and how you fit into the scheme of things.
I agree that it sounds like they’re trying to ooze you out if your previous position (and you may hear that, or something that sounds like that) but perhaps they want to see how you manage a new department because sometime you might be asked to manage both. I have no way of knowing, and you don’t either. Don’t keep yourself guessing. 

[SilverBells, BSN]

My understanding is that they are wanting me to manage the LTC unit as well as the 7 rehab patients that are on my old unit.   Basically, there is a difference of opinion as to where I should be: I feel that I should be closer to the rehab patients because they are higher acuity, however, they want another person on the LTC unit because there are more patients there.  To me, it seems like this is resulting from their inability to hire and keep staff.  The primary needs of the patients on LTC are feeding, toileting and keeping an eye on wandering patients.  None of these requirements need to be met by a manager.  Can I help with them? Yes, but to me it seems they are taking advantage of the fact that I am there rather than addressing the true issue--they need to improve staffing levels.  

[SilverBells, BSN]

Also, I do offer to help out with things, but usually am turned down.  For example, as I mentioned previously, one of my coworkers expressed concern regarding not having enough time to upload and scan documents.  I offered to assist with this, and told them they would just need to show me how to use the scanner.  The executive director and director of nursing were there when I offered.  No one was receptive. 

[JBMmom, MSN, NP]

1 hour ago, SilverBells said:

Also, I do offer to help out with things, but usually am turned down.  For example, as I mentioned previously, one of my coworkers expressed concern regarding not having enough time to upload and scan documents.  I offered to assist with this, and told them they would just need to show me how to use the scanner.  The executive director and director of nursing were there when I offered.  No one was receptive. 

If you're already putting in 16-20 hours, maybe other people are recognizing the last thing you need on your plate is anything additional to keep you from getting out of work. 

I don't understand how your staffing office doesn't realize they don't have scheduled floor nurses. How big is this facility?!

[SilverBells, BSN]

It seems as if the more enthusiasm I show for one task, the less likely they are to accept help with it.  In the case of the task of scanning, there was also discussion about needing to obtain COVID swabs on all employees.  That is when my coworker expressed concern about not having enough time to scan documents.   I might be wrong, but I have a feeling that if I'd offered to obtain the COVID swabs instead of learning to scan, they probably would have accepted that offer.  

The more I explain my rationale for prioritization (e.g. rehab patients are higher acuity than LTC patients), the more I am contradicted (e.g. the LTC unit is also short-staffed; a floor nurse, HUC, and aide should be enough staff for the 5 rehab patients).  Being located on the LTC side would also hinder my ability to complete thorough, detailed assessments on my rehab patients daily because I wouldn't interact with them as much.  And while the nurses working with the rehab patients likely can complete the assessments themselves, they rarely do, or if they do, they are not very thorough.  Thorough documentation and follow up is important on short-term rehab patients who were just discharged from the hospital, but it seems that no one else is in agreement with this.  

Maybe I'm wrong, but it seems that if I view one thing as a priority, I probably should do the opposite.  For example, if there is a choice between following up on a patient who is on an anticoagulant who fell a day ago versus feeding a resident, I probably should go feed the resident.  Maybe then I'll be right.  

 

[Hoosier_RN, MSN]

2 hours ago, amoLucia said:

I don't think you see the bigger picture here. It was said by someone in another post that maybe Admin DOESN'T really WANT you as a UM any longer. I believe that might be the bottom-line truth here.

You were slowly being downgraded into positions that you really didn't 't feel were worthy of your skillset. You complain, you don't freely pitch in to help, you cherry pick tasks. And you continue to do so even when others here have tried to enlighten you. But still you rebuff their observations.

I don't understand your thinking ----

Amo, I think you've hit the nail on the head!