Med aid problems!

[Doobyk]

Hello all,

I am a charge nurse in a SNF; primarily work in our facilities TCU which as many of you know is a whole other ball of wax from usually LT nursing but I am coming to you all for perspective regarding the heavy use of medication aides, or as we call them TMAs in place of nurses.

To give you perspective my facility has 4 units of 20 residents; 3 of the units are LT care and 1 unit is a TCU. The TCU always has a RN as the patients are much more acute and require skilled nursing care. The other 3 units should have nurses on but over the last several years really shift after shift is being filled by these TMAs. The nurse on the neighboring unit should take over and do things like assessments, insulins etc but essentially these unlicensed aides are in charge of the care of 20 people. Over the last few months so many things have been missed on these wings like orders, treatments etc and these units sometimes go 16 hours without a licensed staff assessing the residents. I understand these residents are generally stable but still its alarming to me.

I guess my question is how does your facility use TMAs? How do you assure nursing-specific tasks are being complete? Is this happening elsewhere due to a this nursing shortage?

[sarahlee23, LPN]

At my facility, when a med aid is scheduled on one of our halls for day or PM shift (we never have med aids on at night), the nursing-specific tasks are assigned to the nurses on the other 3 halls. Each of our 4 halls is divided up into thirds, and each third is assigned to a nurse on one of the other halls when there is a med aid. This way the assessments, etc that a nurse must do still get done every shift a med aid covers a hall. For example, if hall A has a med aid then rooms 1-6 are assigned to the hall B nurse, rooms 7-12 are assigned to the hall C nurse, and rooms 13-18 are assigned to the hall D nurse. The nurses check with the med aid and look at the MAR/TAR for that hall at the beginning of the shift, and then periodically check in with the med aid to see if anything has come up. It eliminates any confusion as to who is responsible for those tasks and ensures that the med aids know who to have assess the resident before giving a PRN.

[CapeCodMermaid, RN]

Unfortunately, we aren't allowed to use medication aides in Massachusetts. All the studies I've read indicate that med techs/aides make far fewer medication errors than licensed staff because all they do is pass meds. They don't do treatments, they don't transcribe orders, they don't have to deal with irate family members or rehab staff wanting certain people to have their meds early.

Certainly not every long term resident needs a full assessment every day and they should be fine with getting their meds from a tech.

[withasmilelpn]

Doesn’t seem to be your medication aides are the problem but the expectations of the facility on the RN. To have one RN cover both a skilled unit of 20 and be responsible for assessments, treatments, orders and insulin on 3 other units - for a grand a total of 80 is asking for things to be missed. She’s juggling too many balls, it’s that simple. Follow her for a day, look at her acuity on the unit she’s on, the acuity and behaviors overall, what tasks she’s responsible for (treatments, IVs, wound vac, nebulizers, bladder scanner, EKG, admissions/discharges, teaching, Medicare charting, Care planning, mds, - all the paper/computer work she’s required to do) do a time study of how long it takes for her to do her tasks, paperwork. Remember that tasks change often and remember that even a simple pulse oximeter check can take time if it’s with and without O2, with exertion, or the patient has a low reading. Or the patient is slow and uncooperative. Allow for unexpected emergencies, Falls, skin tears and families needing reassurance,Education etc. Be sure to include how long it takes simply getting from unit to unit seeing patients (remember if there are patients requiring insulin or prns at the same time on different units that is going to add to the inevitable inefficiency and length of time to get things done.) How accessible and stocked are supplies? If you have a computer system, allow for time to log in, freezing, total clicks to get from page to page and other frustrating system hiccups. Look at how things are communicated to the nurse - how is she notified of new orders? Does she have to do rounds with the MDs? If so, how generally time consuming are rounds and how disruptive to her responsibilities? Does she get behind? If she doesn’t do rounds, do they simply leave orders on the units she is not physically on? If so, who notifies her the doctor was here. How many staff are assigned to her on her unit and on the other units? Are they reliable, caring, kind, well trained, efficient and can recognize when they need to speak to the RN? Or do they actually add to her workload? And finally, what do you as a charge nurse do to support her, the caregivers and the facility? Do some investigation and you might find out why.