LTC vs. Rehab Patients: Who Is Priority?

[SilverBells]

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)? 

[SilverBells, BSN]

7 minutes ago, JBMmom said:

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?!

That's possible.  The more work that I take on, the more likely I will stay until midnight or later.  When I stay that late, I end up coming in later in the morning.  Usually, help is needed most in the morning hours.  

But as far as the staffing issues go, that is a good question.  The SNF isn't that large, about 50 patients between three units.  There's really no reason why they can't keep up on staffing concerns. I can see it happening every once in a while, but this is a daily occurrence.  

Instead, they seem to rely on the fact that me and my co-manager are also nurses and that if they can't find someone to work the floor, no big deal--let's just add more work to the same people who are already overwhelmed with their responsibilities. 

[JBMmom, MSN, NP]

2 minutes ago, SilverBells said:

Instead, they seem to rely on the fact that me and my co-manager are also nurses and that if they can't find someone to work the floor, no big deal--let's just add more work to the same people who are already overwhelmed with their responsibilities.

That really makes no sense, I think you would do well to look for new opportunities. Your sense of priorities does not seem misplaced as you present them here, if your facility does not align with your expectations, perhaps you will be better off elsewhere. 

[SilverBells, BSN]

I’ve definitely thought about looking at other positions.  At the same time, I need to do some thinking as to what I want and my approach to work.   Chances are, my superiors and other colleagues are bringing forth to my attention things that are important.  If someone else thinks something is important, it probably is, even if it’s not my “priority.”  I’ve thought about moving on because of the horrendous staffing issues and the fact that I’m constantly expected to be free to work the floor while getting all my manager work done at the same time, which has proven to be very exhausting.  With that said, regardless of position, it would probably behoove me to not be too dictatorial as to what I will and will not do, as anything someone asks of me is important.  It would also help to be mindful of the fact that I am only a unit manager, not the DON, so they technically can assign me anywhere they like.   

[JadedCPN, BSN, RN]

Oh boy here we go again.

It makes sense that they wouldn’t want to pay a nurse to do duties like scanning in documents as that doesn’t require skill, whereas nasal swabbing employees does.

Agree with other posters that there’s a chance you’re being pushed out of your position. 

[caliotter3]

Print out copies of your threads here and show them at a meeting with your managers.  See what their reactions are.  That will tell you what you need to know.

[cardiacfreak, ADN]

22 hours ago, SilverBells said:

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.

Yes, you would be right in this case!  Making sure a resident has his/her meal far exceeds "follow up" of a fall.  Would the nurse on the unit not notify you if there was a change In condition?  Would you want your loved one waiting for assistance to eat while someone went and "followed up" on something that happened yesterday?  

Correct me if I am wrong, I get the sense you like paperwork and hate hands on care.  If that is the case maybe you should look into quality management or MDS positions.

[SilverBells, BSN]

1 hour ago, cardiacfreak said:

Yes, you would be right in this case!  Making sure a resident has his/her meal far exceeds "follow up" of a fall.  Would the nurse on the unit not notify you if there was a change In condition?  Would you want your loved one waiting for assistance to eat while someone went and "followed up" on something that happened yesterday?  

Correct me if I am wrong, I get the sense you like paperwork and hate hands on care.  If that is the case maybe you should look into quality management or MDS positions.

I guess my reasoning for following up on the fall is whenever it is unwitnessed and the person is on an anticoagulant, there is a chance for a brain bleed if we are not sure if they hit their head.  A brain bleed is potentially life threatening whereas I would think waiting a little bit for a meal would not be. 

[SilverBells, BSN]

I've had brain hemorrhages not make themselves apparent until the next day so that was my concern 

[JadedCPN, BSN, RN]

On 3/7/2021 at 1:26 PM, SilverBells said:

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.  

But you think uploading and scanning documents should be met by the manager? Again I think you say the answers that people want to hear and might make sense, but in reality the reason you don't want to do these tasks is ultimately because you don't want to do these tasks.

[cardiacfreak, ADN]

1 hour ago, SilverBells said:

I guess my reasoning for following up on the fall is whenever it is unwitnessed and the person is on an anticoagulant, there is a chance for a brain bleed if we are not sure if they hit their head.  A brain bleed is potentially life threatening whereas I would think waiting a little bit for a meal would not be. 

Yes, there is a chance for a hemorrhage, you will see signs and symptoms, that is why frequent scheduled neuro checks are normally ordered.  Are you the nurse for this patient or are you checking up to make sure the nurse did her job?  There is a difference there.  If you are just following up and another nurse is in charge of this patient you should assist the resident with their meal.

I was in management once upon a time, I was the Assistant Nursing Care Manager of a Progressive Care Unit.  My assignment consisted of 3-4 patients, I was also part of the code team on top of management duties (chart audits, payroll, scheduling, etc)..  I did it all in my 12 hours shift, sometimes 13 hours.  It can be done if you don't micromanage everyone and everything.

[SilverBells, BSN]

59 minutes ago, cardiacfreak said:

Yes, there is a chance for a hemorrhage, you will see signs and symptoms, that is why frequent scheduled neuro checks are normally ordered.  Are you the nurse for this patient or are you checking up to make sure the nurse did her job?  There is a difference there.  If you are just following up and another nurse is in charge of this patient you should assist the resident with their meal.

I was in management once upon a time, I was the Assistant Nursing Care Manager of a Progressive Care Unit.  My assignment consisted of 3-4 patients, I was also part of the code team on top of management duties (chart audits, payroll, scheduling, etc)..  I did it all in my 12 hours shift, sometimes 13 hours.  It can be done if you don't micromanage everyone and everything.

Neuros/vitals were implemented.  While there was a nurse assigned to this patient, she also had to float between two units/wings so I thought it might be helpful to assist in obtaining vitals/neuros.  I was the one who responded to the fall and involved with not sending him in to the ER, so wanted to make sure the right decision had been made 

[SilverBells, BSN]

As a side note, I did end up assisting with the lunch time meal today and found it didn't actually take as much time as I thought it would.  Ironically, by responding to some of the tasks I view as being "time consuming" I was able to work 10 hours vs 16