Nursing Home, chronic understaffing, and dealing with profit driven business owners?

Updated:   Published

I don't care what anyone says, a I think a 1:30 or a 1:60 Nurse to patient ratio is outrageous, unsafe, and not sane. You very well could be putting your license in jeopardy. If something happens to one of the patients under your care, try using the excuse of "we were understaffed, boss did not want to hire and staff more help." You'll be asked why you took on the assignments if you believed that to be the case.

I was hired on as an "RN Supervisor" and quickly became their kill 2 birds with one stone Nurse. They had their mandated RN hours required plus I took floor shift normally done by LVN.

I found myself in an 11p to 7am 1:57 Nurse to patient ratio and only nurse in the building.

I was told to start the morning med pass and glucose checks and 3am!

Thanks to one of the 3 CNA's on shift I was alerted to a patient c/o chest pain and numbness. 911 was called. What if the CNA (who is too busy with own unreasonable workload) hadn't gotten around to that resident? What if the resident died? What if more than one of those 57 had an emergency? You cannot be at the med cart, on the phone, checking glucose, admin. insulin, breathing treatments, charting, and assisting emergency personnel all at once. CNAs are expected to be our "eyes and ears" but they are not trained at an LVN or RN level to assess for significant changes!

Needless to say, this incident put everything else behind. By the time 7am nurses arrived, I was still occupying a med cart. Not only that, breakfast trays do not arrive until about 7:30am. I'm not counting on a glucose read from 4am or giving insulin too early before breakfast for obvious reasons.

Who gets frowned upon in these instances? We do.. because "other nurses can get everything done by themselves with about 30 patients or about 60 on night shift" OR "911 emergency rarely happens on night shift."

I don't see how any nurse can logistically do all... Med passes, all treatments and wound care, all the different S/E monitoring for meds documented to be signed in MAR, "target behaviors" O2 sat monitoring with and without O2, BP and pulse monitoring for ranges, I&O, meal percentages, admin. Nutren and other various supplements for various patients, and all the other entries in addition to meds in the MAR in 8 hours.. plus sign the MAR and TAR books for about 30 residents (about 60 if night shift), complete all the COC, Medicare, weekly charting, etc. in 8 hours unless they cut corners. It is logistically impossible.

For nurses who manage to supposedly get everything done, I say again that it is logistically impossible without cutting corners (and I've seen cutting corners). I've seen boxes of albuterol for nebulizers with vials when they should have been done. Vitamins and other OTCs (not kept with regular med cards.. and used as "house supply") in the cart that should have been finished by now. Signing the thick TAR and MAR books to get signing out of the way, and I've suspected some 3-11pm of combining both the evening and bedtime meds (no significant drug interactions, but still). I complained about the latter because if you give Seroquel or Ativan for instance at 5pm but mark 10pm, guess who's up for the day and trying to get out of bed at 2am for the night shift nurse? Can't give them anything because they last received supposedly at 10pm.

The shortcuts may not be dangerous per se, but shortcuts nonetheless. These are overworked and exhausted nurses expected to do impossible workloads. They are dedicated nurses who are forced to spread themselves thin and prioritize. In addition to the impossible workloads, a "change of condition" (new rash, a cough, wound or what not) can put a nurse an hour or more behind having to call doctor, chart, wait for doctor to call back, chart, get order, fax pharmacy, update care plan, notify family, update MAR or TAR.

Nurses who are skipping lunch and breaks, clocking out at end of shift and continuing to work, coming in hours early to start treatments, etc then clocking in on time to help reduce cutting corners.. it's admirable, but it is behavior that enables the administrators who refuse to hire, staff and retain anything more than the bare bones minimum required by law. It is also used to as an example to other nurses that "see? Other nurses can get everything done!"

Understand that behind many privately owned for-profit nursing homes are owners who have no clinical background and see a big chunk of profit when they can manage to stay at the bare minimum required by law in their state.Staff is the most costly expense for a nursing home. Every state has a bare minimum for nurses and CNA's (which is still an unreasonable workload). Each one also says that the facility shall staff enough employees to meet the needs of the facility's residents which is open to interpretation. A facility that maintains only the bare minimum "one size fits all" is not considering the individual needs of the residents.

I dont suppose pose I'll be lasting too long at this job. I take my time and to make sure that each entry I signed is what I did, even if that means staying hours over.

Before re applying at a LTC facility, I would urge you to check the facility's staffing on a site like Healthgrove dot com. A facility that staffs above the bare minimum is likely to treat their employees better too.

Thats all for my ranting. Thanks for listening and I'd love to hear input.

As few as 2 years ago, I thought I could do anything nursing-related....but LTC broke me. I feel fortunate to have retired (much earlier than planned) with my integrity (and license!) intact.

LTC nurses have my unending respect and admiration. ?

I understand because I happen to be in a similar position. The longer I have been at this facility the more duties I have been given along with more residents to care for. Corporate is driven by profits and puts us in a difficult position. I've seen Nurses cry at work because of the stress. I would search for something different if I were you. Long term care has turned into a circus with the acuity and expectations for care at end of life. I should not be doing such things as calling lab, pharmacy and Dr in the middle of the night. I do not work in a hospital but sometimes I feel like it. Difference is we have 50 patients instead of 5.

On 3/16/2017 at 8:46 PM, TheCommuter said:

Only the threat of impending homelessness would prompt me to return to the LTC industry. I salute those who still fight the good battle in today's nursing facilities

The post I am quoting was well over 2 years ago. I am humbled beyond words to admit that I retired before my time (and may, at some point be faced with homelessness) because of what you faced. Perhaps it was because I'd been faced with similar moral injury and could no longer accept that. I'd rather be poor than return to LTC/Rehab. My hope is that it becomes easier for ALL of you. PRONTO!!!!

The only thing that keeps me from cynicism, from anger and from all those other negative emotions is my belief that this is not all there is, there is a moral order and justice will ultimately win out, in the mean time while I have to cope in the world and my 37 years in healthcare experience is that when it comes to healthcare, money is more important than people, it's that simple and this truth seems to be true in politics, insurance, etc. Sorry I can't help you, I think the only thing that will change this Nihilistic world is massive revolt by the masses.

Bless you. I appreciate your thoughts, garciadiego, and I still believe in those things. Had I spent one more moment in the environment we are discussing, I no longer would believe those things. There is much I still have to offer the world, but without obligation to an employer, my motivation can once again be pure and hopeful.

I'm not a nurse yet- in an LPN program and will graduate in 2021. However, I've been a PCA, HHA, CNA and now a med tech/direct support staff for many years. I used to do private duty, then was offered a job working at a residential home for developmentally delayed adults and have been there for over 6 years now. I hope to stay there after I graduate, but if they don't offer me enough hours or pay (the pay there is not the best) I'll have to find another job. Unless I can find another place like my current job, I'll probably be going into LTC. I love bedside care, and plan to do it as long as I'm physically able to, which will probably be quite a long time. I like to get to know my residents, everything from their behavioral quirks and life histories to whether they take their crushed meds in applesauce or yogurt and their normal vital signs. I enjoy having coworkers too (well, most of them!). We certainly have our issues at my facility, but when I hear about the problems in LTC these days, it worries me. It's terrible that the owners of these places are so money hungry that they are endangering their residents and staff, and driving skilled, experienced nurses out of LTC. It's just creating an endless vicious circle. Without good nurses with proper training, residents will suffer more harm from accidental errors and falls, which leads to loss of $$ for the facilities, which leads to more cutbacks in staffing and less pay, which results in more nurses leaving and the new nurses not having qualified preceptors, which starts the whole thing over again. It's so clear yet seems to just keep getting worse. I know I didn't add anything to the conversation but the perspective of an older new nurse-to-be, but I just had to comment because I think about this issue a lot.

You have my best wishes for long-term success and fulfillment, Fashionably L8. Be that Good Nurse, be true to your patients AND yourself. ?

Specializes in Short Term/Skilled.
On 3/16/2017 at 2:18 PM, AnOldsterRN said:

Why oh WHY do nurses take shortcuts or come in super early to start care care then clock in on time, clock out but never leave for lunch then clock back in, lock out and continue working? I absolutely won't do that. I suspect I'll be let go due to that.

If more nurses stuck together with regards to the impossible workload, perhaps things might change.i don't see that happening though. It's going to take the law and their are bones minimum staffing.

I suck at time management. I spend too much time talking to my patients and doing "extra" stuff for them. In order to allow this, I sometimes document off the clock. If I stay clocked in I get in trouble. If I rush through my documentation, it is sub-par at best.

Today I had a discharge, an admit, and a patient actively dying who was getting morphine every hour. That's on top of my other 15 residents. I consider myself lucky because this facility is the best I've ever worked at and the staff are amazing. Management is amazing too. Its just a broken, broken system.

I stay because I love what I do. I love it. I love having some rehab patients, some long-term and some hospice. I love getting to know these people and making a difference in their lives. I love being able to bring things up to the MD and have them addressed when other nurses just blow it off. I feel like I'm helping them and making their lives better.

But, I digress. Its a horrifically broken system and society likely has no idea what goes on.

The kicker is we are almost always in the red. medicaid payments are at an all time low, and most of our medicare patients only stay for short durations. We mostly get cardiac and respiratory pts. that don't qualify for acute rehab. So, while people think the facility is being cheap and someones pockets are getting lined, they're actually losing money.

+ Join the Discussion