New Director of nursing

Specialties LTC Directors

Published

I was recently hired as director of nursing of nursing home. Unfortunately 3 weeks before I start they had their state survey. I was hired the day after the surveyors left. They received 29 tags. The previous director was fired and the intern director walked out. I have been in this position 7 days. I came at the worst time possible because everything has fallen through the cracks. I;m expected to fix all of these tags they received. Let;s just say I;m going to need to re create the wheel in every area. Everything has been lost from previous inservice training to any kind of tracking logs for things such as infection control, falls, antibiotic monitoring logs, psychotropic monitoring, no tracking of attendance, no follow through at all. We have very little nurses and use 80% agency staff. The place is in complete chaos. Every day I walk in we are getting pulled in every direction. My 6th day I was told I had to complete Plan of correction of the 29 tags along with audits on each tag- 3 audits per week through 4 weeks and they wanted it done on that day by 3 pm. This is not including psychotropic follow up that has not been done. We have about 20 pages of psychotropics in this facility this alone could take days to complete. I have enough work for 6 managers and I'm having demands made on me to get this done NOW. I had no real orientation as a new director and being expected to fix this building that is falling apart. Is this even possible? There is no communication within departments. I could go on.. just picture yourself walking into a disaster zone and told you must fix this now.

Specializes in retired LTC.

Wow! Sounds like someone really had it out for the facility to so sabotage it by removing all record keeping and the props you need to do your job. Sounds like a sabotage job - who else would now how to so purposefully destruct the facility. Of course, the facility may have been in serious jeopardy before you came.

Question is do you have DON experience? Maybe at least some very solid LTC experience? What was the previous survey like?

You've got your job cut out for you. This room does have some very experienced people who can be good resources.

Welcome to AN and good luck to you.

Specializes in LTC, assisted living, med-surg, psych.

The same thing happened to my son, who was the DON for an intermediate care facility. When he went into the job, the surveyors had just exited and they issued 26 citations just for nursing and he had to come up with a plan of correction in a matter of a couple days. They were seriously understaffed and he worked the floor routinely on weekends. The staff turnover was almost 100% in the six months he worked there. He wound up getting fired because he wasn't able to fix everything, even though the number of citations on the surveyors' re-visit went down to 5 from 26. He was so happy when it happened...the only thing he regrets is that he didn't quit before he was let go.

2 Votes
Specializes in Gerontology, Med surg, Home Health.

Welcome! You can only do what you can do and you only have a certain amount of time in which to get it all done.

Look at the tags. The plan of correction has to:

speak to how you're going to fix it for the resident it applied to

how are you going to determine who else could be affected by the deficient practice

the education

the audits

Make the plan be realistic....don't say you're going to audit every MDS every day...or whatever....enlist all the other managers to help you do audits.

In Massachusetts we always do our audits for 90 days.

Do you have a staff ed person? Get her on the education and have her help with the audits. You can do this.

1 Votes
Specializes in Director of Nursing.

I gave it my all. I worked myself to basically destroying my life outside of work. I made it through the tags they received. And was reminded before I decided to leave- by the administrator

“ Do you understand what you have accomplished? You helped us get out of 20 or more tags with 10 IJ.” I got nursing assistants raises higher then our competition, put my heart and soul in this job. I had no life outside work. Decided enough was enough when I was supposed to have 2 ADON and had none. Running a facility with over 120 residents. A facility that had maybe 5 regular nurses and used all agency staff. I was chasing my tail trying to save a broken system.

1 Votes

I know this is old, but it's something all DONs need hear: All of this starts with your job.  If a facility is getting that many citations, there's serious problems in how it's being run.  If your staff hates the job, you're going to do horrible in your inspections, because they just don't care.  Make the job a job that your staff WANTS TO do everything perfect for. 

Some advice:

1. Get staff.  Can a nurse take care of 30 patients in an LTC facility, yes, they do it all the time.  SHOULD they?   Well do you REALLY think they know what's going on with resident #4 while they're still on their med pass giving meds to #28?  There are 0 situations where staffing like that is ever a good idea.  If it means that nurses have more downtime, they can help the aides.  If everyone ends up with downtime, that means your residents are actually taken care of.  And do you REALLY think your nurses are putting those creams and powders on your residents?  They barely have time for their med passes if they do it correctly.

2. Follow through on training.  ESPECIALLY new nurses.  Go onto the floor and see how new hires have their training be to get all of the vitals and blood sugars on all the patients.  You can't have this happening.  ALL orientations need to have some kind of uniform plan and progression and the trainer/preceptor NEEDS to be held accountable for actually training your new hires.  And COMPLETE their orientation period before throwing them on the floor on a med cart.  Even if they have 40 years of experience, it can be 40 years of being a bad nurse.  Do not put anybody out there working independently until the ENTIRE orientation is completed.

3. New policy: Come to work or get fired.  You have to put your foot down on any callouts, so that you can replace bad staff with better staff.  It's not just to make sure you have people, it's to keep your good nurses and aides willing to put in the effort it takes for you to not have problems on inspections.  Let them care about the job and they'll work hard for you.  If they're constantly working short staffed, they're there for a paycheck.

4. Be a leader.  Talk to your nurses.  Put a complaint box up to let them anonymously tell you what they don't like that's going on on their floor.  You have to actually fix the problems.  They're not going to go away on their own.  All you're going to do by not stepping up is cause more turnover, making the job that much harder on your nurses that stay.

5. Right now, while I'm posting this, you're working out of an office, they're risking COVID infections that they can bring home to their families.  Times like this are the wrong time to make trivial policy changes.  Instead, focus on adequate staffing to cut down on the number of times anyone has to go into a room.  Make sure you have the supplies your staff needs.  Maybe even get out there and help.  Changing how they're charting something because you feel it's a better way to chart can wait.

6. PTO/Vacation: Your staff earned it, it's a benefit given by the company.  Let them take the time off.

7. Weekends / Holidays: some of your staff probably works a set schedule, working every weekend, while the rest get every other weekend off.  Guess which one of the two should never be required to cover a holiday.  You have to be fair.

8. Evenings and weekend shifts: If you feel the need to have 4 nurses on the floor, plus a supervisor, plus a building supervisor every day shift, then guess what you also need every evening, night, and weekend shift.

9. Use negativity to your advantage.  If there's a nurse constantly complaining, maybe take the hint that there's something seriously going wrong with the job for that person.  Don't write them up.  Sit down with them and ask them honestly what they believe needs to be fixed.  Some people are just negative, but negativity to the point of being disruptive, there's something bigger going on.

3 Votes
Specializes in EMS, LTC, Sub-acute Rehab.
On 11/16/2020 at 5:38 PM, TheDudeWithTheBigDog said:

I know this is old, but it's something all DONs need hear: All of this starts with your job.  If a facility is getting that many citations, there's serious problems in how it's being run.  If your staff hates the job, you're going to do horrible in your inspections, because they just don't care.  Make the job a job that your staff WANTS TO do everything perfect for. 

Some advice:

1. Get staff.  Can a nurse take care of 30 patients in an LTC facility, yes, they do it all the time.  SHOULD they?   Well do you REALLY think they know what's going on with resident #4 while they're still on their med pass giving meds to #28?  There are 0 situations where staffing like that is ever a good idea.  If it means that nurses have more downtime, they can help the aides.  If everyone ends up with downtime, that means your residents are actually taken care of.  And do you REALLY think your nurses are putting those creams and powders on your residents?  They barely have time for their med passes if they do it correctly.

2. Follow through on training.  ESPECIALLY new nurses.  Go onto the floor and see how new hires have their training be to get all of the vitals and blood sugars on all the patients.  You can't have this happening.  ALL orientations need to have some kind of uniform plan and progression and the trainer/preceptor NEEDS to be held accountable for actually training your new hires.  And COMPLETE their orientation period before throwing them on the floor on a med cart.  Even if they have 40 years of experience, it can be 40 years of being a bad nurse.  Do not put anybody out there working independently until the ENTIRE orientation is completed.

3. New policy: Come to work or get fired.  You have to put your foot down on any callouts, so that you can replace bad staff with better staff.  It's not just to make sure you have people, it's to keep your good nurses and aides willing to put in the effort it takes for you to not have problems on inspections.  Let them care about the job and they'll work hard for you.  If they're constantly working short staffed, they're there for a paycheck.

4. Be a leader.  Talk to your nurses.  Put a complaint box up to let them anonymously tell you what they don't like that's going on on their floor.  You have to actually fix the problems.  They're not going to go away on their own.  All you're going to do by not stepping up is cause more turnover, making the job that much harder on your nurses that stay.

5. Right now, while I'm posting this, you're working out of an office, they're risking COVID infections that they can bring home to their families.  Times like this are the wrong time to make trivial policy changes.  Instead, focus on adequate staffing to cut down on the number of times anyone has to go into a room.  Make sure you have the supplies your staff needs.  Maybe even get out there and help.  Changing how they're charting something because you feel it's a better way to chart can wait.

6. PTO/Vacation: Your staff earned it, it's a benefit given by the company.  Let them take the time off.

7. Weekends / Holidays: some of your staff probably works a set schedule, working every weekend, while the rest get every other weekend off.  Guess which one of the two should never be required to cover a holiday.  You have to be fair.

8. Evenings and weekend shifts: If you feel the need to have 4 nurses on the floor, plus a supervisor, plus a building supervisor every day shift, then guess what you also need every evening, night, and weekend shift.

9. Use negativity to your advantage.  If there's a nurse constantly complaining, maybe take the hint that there's something seriously going wrong with the job for that person.  Don't write them up.  Sit down with them and ask them honestly what they believe needs to be fixed.  Some people are just negative, but negativity to the point of being disruptive, there's something bigger going on.

I worked LTC/Subacute for 4 years. I agree with everything but item #3.

Call-outs should be evaluated on a case by case bases. They should also be balanced to the call-in schedule. For example, I picked up shifts to help the company but when I needed off. I had to find my own coverage. So it was better to just call out then try to schedule time off. 

There aren't unlimited resources for hiring new nurses or aides. Training takes time and money for new employees. If you fire everyone for a no-show you're going to figure this out very quickly. You're also going to figure it out when you front load all of your 'good employees' with extra work b/c you fired 'bad employees' prior to replacing them.

A good leader needs to provide purpose, direction, and motivation. State Inspections rarely impact the quality of patient care and never address the problems of nurses or aides such as staffing or supply shortages. Most people are there for the pay check and do not to care about regulatory oversight. 

You don't have to fire everybody.  But when nobody ever gets in trouble for constant callouts, that's when callouts get out of hand.

I understand that people have things that they have to handle outside of work, but workers in literally every other field make it work.

Yeah, OCCASIONAL callouts are going to happen for everybody.  When every single Saturday is being worked short staff by only the same people who actually show up and the same people are calling out, that's not being siick or having an emergency come up, that's a habit.

1 Votes
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