New DON

Make a list of priorities for the day, week, then month. Anything that impacts patient care should be at the top of your list.

Do a chart review on every resident. With only 25 charts, it shouldn't take a month and once you've done them all one time, the next review will be easy. I'd suggest doing a quarterly review that follows the care plan schedule.

Look at systems...who monitors wound documentation, falls, incidents, pain, infection control.....you should figure that out pretty quickly since those areas impact patient care and are scrutinized by DPH.

Review all the MARs and TARs for completeness and for orders that make sense. We had a few docs who would write sliding scale insulin orders for Mon. Wed. & Friday and no one ever questioned them. I had nurses in one place signing off that they "monitored the hip incision"....for FOUR years. Made me see that they weren't reading what they were signing.

With 25 residents, I'm not surprised you don't have an ADON or an MDS nurse. Just make sure whoever is doing the MDSs knows when they are due so you don't go to the land of default.

You should call all your vendors and have them in to meet you...especially your pharmacy consultant and your medical supplies company rep.

Good luck.

Wow, good ideas. Thank you so much. The prior DON had an assistant who did everything for the staff nurses for so long that they have forgotten their job tasks. They truley think it's not their job to finish an order or do their own admissions. I gave one nurse specific, one on one, instruction on a new order on a friday. On Monday I discovered she never bothered to complete it, and stuck it in a pile of "to be filed" papers. I have inserviced and encouraged till I'm blue. Had to write her up for not following policy and procedure. Not just once, but a second time as well, with final warning. That seemed to be effective. I have assigned specific nurses to do tracking such as an RN for wounds and infection control, the rest are lpns assigned to wts,NAR, MAR/TAR and MD orders review, Falls/incidents and Certain sections of the MDS related to the specific tracking each does for starters. I am the MDS coordinator and do the careplans and restorative. We recently had to give up our restorative aid and will be inservicing the other CNAs to pick that up. I appreciate your advice and will alter my task lists. Right, there is only 25 res. so once everything is organized it should'nt be hard at all. Thanks again!

I have been the DON in 60 bed facility, 120 bed facility, and 180 bed facility. The one thing that I always did was to not schedule anything in the morning time. That was my time to be out on the floor talking with the residents, helping make beds, helping with toileting, etc. You would be amazed at the things you learn when you are the one that answers the call light. LOL. I would spend every afternoon on all of the paperwork and various meetings that needed to be held. Hope that helps.

This is a terrible job. You all have my admiration. I have met with so much resistance from "the powers that be". I'm fairly certain I was set up to fail. Back in April, after review of a referral, I had advised we could not meet this particular patient's needs. Marketing sends out a corporate wide email, " with the census low, we will have to work harder and put up with the more difficult patients" insult...slam....yada yada. Then regional shows up unannounced and holds a meeting on the new admission process which did not include the medical advice of the DON. Admin was to go directly to the referral source and accept the patient. No where in the process was the DON mentioned except to be provided with a typed summary from the admin, of the patient who was coming and what their needs were. I believe this change was and is against state rules. Anybody want to guess how that has worked out? I was not allowed to hold inservices because they didnt want to pay for it and they cut back on my staff hours. When we started to grow, I asked for more staff back and advised we were not meeting pt care needs. They said, give me a time study. OK, so we do one. Then I'm told "ok, write an add and we will put it in the paper". So I write it with HR input, give it to them. 3wks go by, every day in am meeting " gee, sure is odd no one is applying". Well, they never put the add in the paper. I dont live in the area and dont get their paper. I didnt think I should have to check and see if they actually did it. Now here we are, twice the census, same amount of staff, patients are angry, staff is crying, Medical director is upset, not at me, he says he'll quit. We are in our state window and everything's a mess. I am done with this garbage. Its only a matter of time before it implodes. I'll never put myself in that kind of position again. Lesson learned. I'm an idiot, 2 thumbs up, to all you tough DONs out there.:heartbeat

Fulzgold, I think we might have worked for the same company. I worked at one place where the admissions people were told not to consult me, the DNS, before admitting someone if census was low. Mind you, neither of the admissions people had a clinical background and got a bonus for every day the beds were filled. This policy didn't last too long. I reminded them that I was the one with a LICENSE and it would be my license and the administrator's license on the line if we took someone we were unable to care for. My decision could be over ridden by corporate. I kept an I Told You So list in my desk. When they started insisting we take people who were very clinically complex on one hand but wouldn't increase the staffing on the other, I left. At my current facility,I have two admissions people both of whom are nurses. I don't get involved in the admission process unless there is something highly unusual or costly.

I spent my first few months as DON thinking that once I got all the fires put out, then I could really get some stuff done. Then, in the midst of a complaint survey, I came to the realization that there is always going to be a fire no matter what! Once I realized this, it stopped bothering me that there were fires. Now, I make a triaged to do list every morning and squeeze it in around the situations that come up.

I firmly believe in an open door policy. I really want the staff, the residents and the families to come talk to me but just this week I have decided that at least twice a week I am going to begin closing my door for an hour or so in the afternoon. I can't get anything done! There are times when they are lined up 2-3 deep outside my door and the phone is ringing in on 2 different lines!

I'm just going to draw the line in the sand - I need some quiet time too!

Wow, you poor thing. I know what you are going through as when i worked as adon, medicare coordinator opening up a new skilled unit in our ltcf i was swamped with staff complaints, nurses problems, etc. etc. etc. staffing problems. The first thing that I finally learned was that for all of those cna complaints and problems, don't feel like you need to give them an answer right away. Have a meeting w/ your cna's and make up a new rule that all complaints need to be submitted in writing with their name, date etc... unless its an urgent matter. Then you need to somehow teach the charge nurses that thats what they are, CHARGE NURSES and dont need to be running to the DON for everything that pops up. They need to know what they can take care of by themselves and what needs your attention. You have a lot on your shoulders and its a tough job but as long as you prioritize your work load, knowing that you have deadlines with mds transmissions you need to concentrate on that however, with 25 residents that shouldnt be too terrible. I devised a form for my cnas for the res. act. dly living status as to howthe res. functioned in the 7 day assess. period. Im not sure about the forms as its been a while but you need to delegate as much as possible. Assign one nurse an RN to do skin treatments and skin sheets. I would read through the past 3 months of nurses notes to see if the res. had a fall and tally them. I would also read through the other disciplines during the past few months and you can really develop a picture of that person and whats going on. Then you can determine if MR. Smith fell was an adequate assessment done, is he more confused than usual check the labs for the past 3 months to see if he was checked for a uti and what the test results were. Were antibiotics given and a couple ofweeks after antibiotics were finished was a repeat ua done to make sure he was now negative for uti. You get the picture. What you may need to do is give the nurses more things to do as there are only 25 res. I took care of 109 w/ a 33 of those beds skilled so people were coming and going and i was in charge of it all. you may want to look at your care planning program/ mds program and update to a better system if applicable. The word is Delegate, Delegate, Delegate. Treat your staff fairly. Know when to rock the boat. Get support of your administrator. And don't be afraid to help out on the floor if you have time or you are short of staff. Your employees will respect you for it. Good Luck. I don't envy you but know that you have an important position. Also devise some kind of routine and try to stick w/ it. Get around to your residents so you know whats going on w/ them. You will learn a lot as you go.