Nursing Home Supervisor challenges with WOUND CARE

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Hello everyone,

I'm in SERIOUS need of advice, please. I started a nursing home supervisor job in the summer of 2017 and, even though I've been a charge nurse in my 22+ year career, this supervisory role is new for me. I have a more laissez faire type management style and I'm working on becoming more respectable as a manager. I can only do so much, it feels like, though. I have a dual role in my job and I'm a wound care nurse at my facility as well.

The LPNs are supposed to do weekly skin assessments on their assigned group of residents and that doesn't always happen. Months ago, I let everyone know that corrective actions would start happening if they didn't do them and print them out for me to review... it didn't seem to matter. I still get 2 out of 3 or 3 out of 3 in a 5-week review period. So, for those who I notice only do their assessments sporadically, I've done corrective actions. One nurse has pushed me to do 2 on her within the last 4 months. She has a HORRIBLE attitude anyway... So, fine. NOW I'm having issues with the nurses not doing their dressing changes-- they sign them off to be done but don't actually change the dressings. I had to write up 4 people for this last week. All of them had excuses and said they "meant to do them but forgot" or "the computer changed the entry from an "N" for "not done" to" their initials accidentally. Do you believe that??? Insert *eye roll* here. So I'll have to keep a check on this very closely from now on. I can't believe they don't understand the seriousness of this neglect. Because that's exactly what it is... !!!

My main dilemma and why I'm posting for advice is in regards to my CNAs and the fact that I can't get them to consistently use heel protectors, float heels, turn people off their backs and use pillows (that's so BASIC!!!!) and I've even implemented the use of disposable foam wedges to turn our residents with actual wounds on their backsides OFF of their bottoms. I can't get them to use them consistently. Some units are good about it and some just like to keep them on the resident's chair, on the floor or lying beside them in the bed but not actually UNDER them where it's actually doing the person any GOOD.

There are 3 shifts and I'm only there for 10 hours a day, 4 days a week. I've asked for the help of unit managers and for other supervisors but they also have their own jobs that they are trying to juggle. The DON said that it's the LPNs responsibility, as well as the CNA's, to make sure the resident is being cared for properly. I understand that... but how the heck do I drive home the seriousness and that there are consequences to their not doing what they are supposed to do? I don't even think they would care if I wrote them up to the point where it was a final warning. I don't even think HR would let someone get fired over not using a foam wedge. But then it's MY responsibility. I'm just at a loss and need advice from someone who is maybe going through something like this or who has gone through this in the past. What have YOU done??? What works to make people 1) CARE and 2) do what you ask of them?????

I organize the inservices for the CNAs every month and even when the inservice isn't about pressure ulcers, I still mention this as being super important. YES, we have agency CNAs and LPNs as fill ins but they aren't always the problem. :( It's our own staff as well.

Thank you so much!

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Specializes in Med/Surg, Academics.

I guess my first question is if you've asked the staff WHY these basic cares are not being done. You've assumed the reason it's not being done (laziness) and implemented a solution (write-ups when it's not done) without investigating what the real reason is with your staff.

Maybe it is pure laziness, but the fact is, you don't know that for sure.

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Hello everyone,

I'm in SERIOUS need of advice, please. I started a nursing home supervisor job in the summer of 2017 and, even though I've been a charge nurse in my 22+ year career, this supervisory role is new for me. I have a more laissez faire type management style and I'm working on becoming more respectable as a manager. I can only do so much, it feels like, though. I have a dual role in my job and I'm a wound care nurse at my facility as well.

The LPNs are supposed to do weekly skin assessments on their assigned group of residents and that doesn't always happen. Months ago, I let everyone know that corrective actions would start happening if they didn't do them and print them out for me to review... it didn't seem to matter. I still get 2 out of 3 or 3 out of 3 in a 5-week review period. So, for those who I notice only do their assessments sporadically, I've done corrective actions. One nurse has pushed me to do 2 on her within the last 4 months. She has a HORRIBLE attitude anyway... So, fine. NOW I'm having issues with the nurses not doing their dressing changes-- they sign them off to be done but don't actually change the dressings. I had to write up 4 people for this last week. All of them had excuses and said they "meant to do them but forgot" or "the computer changed the entry from an "N" for "not done" to" their initials accidentally. Do you believe that??? Insert *eye roll* here. So I'll have to keep a check on this very closely from now on. I can't believe they don't understand the seriousness of this neglect. Because that's exactly what it is... !!!

My main dilemma and why I'm posting for advice is in regards to my CNAs and the fact that I can't get them to consistently use heel protectors, float heels, turn people off their backs and use pillows (that's so BASIC!!!!) and I've even implemented the use of disposable foam wedges to turn our residents with actual wounds on their backsides OFF of their bottoms. I can't get them to use them consistently. Some units are good about it and some just like to keep them on the resident's chair, on the floor or lying beside them in the bed but not actually UNDER them where it's actually doing the person any GOOD.

There are 3 shifts and I'm only there for 10 hours a day, 4 days a week. I've asked for the help of unit managers and for other supervisors but they also have their own jobs that they are trying to juggle. The DON said that it's the LPNs responsibility, as well as the CNA's, to make sure the resident is being cared for properly. I understand that... but how the heck do I drive home the seriousness and that there are consequences to their not doing what they are supposed to do? I don't even think they would care if I wrote them up to the point where it was a final warning. I don't even think HR would let someone get fired over not using a foam wedge. But then it's MY responsibility. I'm just at a loss and need advice from someone who is maybe going through something like this or who has gone through this in the past. What have YOU done??? What works to make people 1) CARE and 2) do what you ask of them?????

I organize the inservices for the CNAs every month and even when the inservice isn't about pressure ulcers, I still mention this as being super important. YES, we have agency CNAs and LPNs as fill ins but they aren't always the problem. :( It's our own staff as well.

Thank you so much!

If it's super-important, which I agree that it is, why not have dedicated staff for these tasks? If you're using agency, I'm betting you're horribly staffed to start out with. Threats won't result in action if you simply lack manpower.

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I guess my first question is if you've asked the staff WHY these basic cares are not being done. You've assumed the reason it's not being done (laziness) and implemented a solution (write-ups when it's not done) without investigating what the real reason is with your staff.

Maybe it is pure laziness, but the fact is, you don't know that for sure.

As mentioned, the LPNs tell me that they "forgot" to do the dressing changes and "meant to go back and do it but then got busy and forgot." That's what I got from all of the LPNs that I did corrective actions on for signing off their treatments but then not doing them.

As far as the CNAs go, no, I didn't ask them why they aren't using the heel protectors or pillows or wedges. I have talked to them until I'm blue in the face in all of the inservices that I've had... I've mentioned HOW to use them properly... I've gone up to individual CNAs in the hall, asked them if they had a particular resident who is supposed to have a wedge, and told them that they MUST have the wedges. I have gone up to them while like 10 of them were at lunch and told them that none of the residents who were supposed to have wedges behind them had them in use... they were ALL on their backs on my rounds.

There are signs above the beds of all of the residents who are supposed to have wedges, heel protectors, etc. It doesn't seem to matter.

When I have spoken with the LPNs about reminding their staff to use the heel protectors, wedges, pillows, they said that they will tell them and they will do good for like 2 days but then it goes back to NOT happening. So... yes... it's been mentioned and I either get blank stares or blank stares... I get NOTHING else in response.

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If it's super-important, which I agree that it is, why not have dedicated staff for these tasks? If you're using agency, I'm betting you're horribly staffed to start out with. Threats won't result in action if you simply lack manpower.

The dedicated staff for the dressing changes is the LPN on that hall. She (or he) is the medication and the treatment nurse all in one. As far as the application of heel protectors, use of pillows and wedges... that's the CNA and/or the LPN who is turning the resident routinely. We aren't horribly staffed... We had a couple of nurses leave recently or take a different position. Then there's one out who got injured and has had several surgeries so we are stuck with her slot being saved for when/IF she decides to return. It's been like a year that she's been out. So 1 slot won't be filled... we have to save it for her. The other 2 slots... well, we will get them filled if people pass their drug screens/background checks. :( You know how that goes. Sigh... Nursing home work is hard. Let's face it. We do have agency that we use to fill in for CNAs more so than LPNs though. When we have looked at the numbers for our manpower versus our census, we are actually staffed really well.

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Specializes in Case manager, float pool, and more.

Sounds like you are doing good so far in taking corrective action, in-services and 1:1 counseling. Is there a way to find out why this is not consistent? What are the barriers to taking time to turn patients, etc. Are your nurses labeling the dressings? I always initial and date/time any dressings I apply. Even if they "forget" to document, you could still see on the dressing itself if that supports their claim.

Have them sign a statement acknowledging they understand the importance to wound care prevention/intervention and know who to sign off on treatments. It seems this is a bigger issue that has gone on for a long time. I wish I had some clever or good advise. I guess, just continue to be consistent in your approach and eventually, slowly, maybe the culture can change.

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Specializes in NICU, ICU, PICU, Academia.

Someone might need to lose their job. Because clearly the "corrective action" is neither.

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"The DON said that it's the LPNs responsibility, as well as the CNA's, to make sure the resident is being cared for properly".

You have reported this up the chain. It is now the DON's responsibility.

You have done your best, get outta dodge.

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Specializes in Critical care.

They are doing false documentation- maybe have a chat about ramifications with the BON.

Also if the company won't let someone get fired over this stuff maybe a chat with the risk manager is in order. If a patient develops a pressure injury and goes septic or goes septic from dressing changes not being completed the company will have an even bigger problem...

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Sounds like you are doing good so far in taking corrective action, in-services and 1:1 counseling. Is there a way to find out why this is not consistent? What are the barriers to taking time to turn patients, etc. Are your nurses labeling the dressings? I always initial and date/time any dressings I apply. Even if they "forget" to document, you could still see on the dressing itself if that supports their claim.

Have them sign a statement acknowledging they understand the importance to wound care prevention/intervention and know who to sign off on treatments. It seems this is a bigger issue that has gone on for a long time. I wish I had some clever or good advise. I guess, just continue to be consistent in your approach and eventually, slowly, maybe the culture can change.

There are no VALID reasons ever given as to why someone in particular is not doing their job. There just isn't. It's like talking to a 5 year-old, honestly. Trying to find out why they stole a cookie from the cookie jar... I have never seen so many people try to shift responsibility and give excuses in my life. It's so disheartening. I'm trying my best to not let it get to me on a personal level. These little old people rely on us to take care of them to the best of our ability... Where are these people's consciences? I guess they are still able to sleep beautifully at night. It baffles me to no end.

The barrier to taking the time to turn a patient, apply heel protectors, use the wedges, etc... ? DESIRE. That's the only thing I can figure. There are no other barriers.

The nurses are labeling the dressings, yes. There's always a date and initial on the dressings. They are good about THAT.

That's a good idea about signing a statement acknowledging understanding about the importance of wound care prevention and intervention... but that's what's done in inservices, you know? When they sign the attendance for the inservice. And, again, when they sign the corrective actions. One nurse is ridiculous and refuses to sign the corrective action as if it makes it not matter/count towards her record. It even says at the bottom of the corrective action that signing it just means it was discussed and does not mean she agrees with it. But whatever. LOL I'll keep on keeping on. Thank you for your reply. ;)

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Someone might need to lose their job. Because clearly the "corrective action" is neither.

Yes... That may come to pass... as the corrective actions are "Verbal warning" then "written warning" then "final warning"... I'm learning... so there might be a warning before the final warning... But guess what? They reset after 1 year. One nurse had like 2 final warnings in her file before I wrote her up over not changing a dressing but signing off that she had done it. This dressing change was to be done every 3 days and she signed it off twice that she did it... So that means 1 week of the same dressing in place. Awesome. :(

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"The DON said that it's the LPNs responsibility, as well as the CNA's, to make sure the resident is being cared for properly".

You have reported this up the chain. It is now the DON's responsibility.

You have done your best, get outta dodge.

I communicate with the DON constantly about this kind of thing... She's fully aware of what's going on and she's supportive of the corrective actions that we are doing. The thing is... our facility is rated as "5 star" and we would like to keep it that way. We are proud of our rating... I'd like to help a facility I work at stay with a good reputation... I don't understand others who don't take pride in their jobs. If we gotta slowly weed them out... so be it. It's unfortunate though... But a necessary fact.

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