Nursing Home Supervisor challenges with WOUND CARE

Nurses General Nursing

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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!

Specializes in Med-surg, telemetry, oncology, rehab, LTC, ALF.

I worked in a supervisory role (meaning I was the only RN in the building during the 3-11p shift most nights) in LTC, prior to switching back to acute care. More often than not, I was the one making the schedule for the week ahead. So if we were short staffed, it meant that I was making mistakes somewhere. I used to schedule a "treatment" nurse for as many nights as we could afford. An extra RN or LPN who would do all of the treatments, skin assessments, dressing changes. This took it off of the shoulders of the hall nurse. We also had CNA II's who could help with treatments and dressing changes (but not assessments). Just something to ponder.

Even then, I still had problems with staffing from time to time. Whenever I encountered staff that I noticed were purposefully not doing their jobs, I would "rotate" them off of "their" favorite hall (most LTC nurses have one, believe it or not) for a week or two.

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Specializes in kids.

That being said, I've never seen an LTC properly staffed, budgeted and supplied unless it was private pay and didn't accept medicare or medicaid. Maybe you work in one of these magical mythical unicorn filled places, I don't know.

Ha!! Private pay facilities are just as short staffed....

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I worked for a year ltc. Too many pts. that needed special care with wounds and such plus giving tons of meds in various forms, dementia patients, o2 dependant patients. I tried getting through all the required needs of patients and was labeled as not having good time management skills. Other nurses, who mgmt. didn't have a problem with, I know firsthand were charting that meds and treatments were being done when they weren't. It really wears you down over time and I had to get out of that job.

That being said, overworked and underpaid equals poor staff morale and a feeling of indifference over time.

Perhaps you could get more done if you offered incentives instead of punishments? A feeling of we're all in this together and ways of getting the job done together would help. Make a chart for yourself to check off of the patients that need various protectors and wound changes and make the rounds every day. Give incentives and praise for jobs well done. Ask how can i help you get this done. Over time with this routine people will react accordingly. If you make it your priority they will make it theirs also. It's human nature. I have always reacted poorly to punishments but I'll work my butt off for someone who gives me praise and thinks I'm doing a good job.

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Specializes in EMS, LTC, Sub-acute Rehab.
Ha!! Private pay facilities are just as short staffed....

The last private pay I worked for was the closest thing I've ever seen to fully staffed. 1 Nurse to 25 Pts. 1 Med Tech. 1 CNA to 6 Pts. The work was a bit demanding at times, due to the socioeconomic status of the Pts. Most were retired physicians, engineers, lawyers and such. The NP or PA rounded weekly to all Pts. Wound care was subbed out.

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

I've only done a few corrective actions on people since I've worked there because I didn't really know the staff or have a feel for how they worked/did their jobs. I had spoken with the DON and the ADON on multiple occasions, as well as the nurses and CNAs... I suppose I didn't want to bust in there and start writing people up left and right without justification and knowing all of the facts... and without seeing a pattern with the people in question.

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Sounds like there is a culture of pre charting. That needs to be addressed. I agree with the nurses that said they "forgot." That's the danger of charting something you have not done yet. Here's a question: Do the LPN's know how to do a propper dressing change? Do they have the supplies? Do they have enough time in the day to do so?

Thank you for your reply. Yes, that was stressed when the corrective action was done: pre-charting before you have actually done the task. It was stressed with each of the individuals multiple times. Do they know how to do a proper dressing change? Yes. None of the dressing changes are complicated and if they were, I would address that and go over the dressing change with them... They are all pretty basic dressing changes and these are seasoned nurses. The supplies are there, yes. We get some supplies from AMT for certain residents and they are in little boxes in the med room. :) They have 12 hours to do a few dressing changes so I think that's adequate time. None of the dressing changes take a large space of time to do.

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Part of my management approach is to ensure that the staff have all the supplies to do their job. Do yours have dressing trollies, correct dressings and enough of them, sterile gloves in the correct size etc?

Do they need leg lifters to attach to the hoist to lift a leg for a heel dressing if the patient can't lie prone for the dressing?

Thanks for your reply. They do have all of the supplies that they need. There's a wound care cart but I'm the one who mainly uses it as I have to assess approximately 25 wounds once a week... and then ones that might pop up here and there in between that time. They gather their supplies for 1 person and take them to the room. There aren't that many wounds per hall that a cart is needed. Overall, the facility I work at has a really good reputation. We just have a few wounds that are challenging and/or stalled. We have an outside wound care company that helps us once a week with debridement and suggesting certain wound care treatments. Grateful to have them come in and help so the resident doesn't have to go to a wound care doctor elsewhere/outside the facility.

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I never heard of a Nursing Home Supervisor. It sounds to me like an administrative title so that might be part of your problem. Also, if you've never worked the floor in an LTC as nurse, I wouldn't expect a lot of respect or compliance. I've seen too many 'seasoned' hospital RNs walk into the LTC only to turn around and walk right back out because they don't understand the culture or worst, though it was going to be some cake walk.

I wouldn't go around threatening people's license unless you have enough evidence to bury them criminally and enough money to defend yourself in court. These are the people who know where all of 'the bodies are buried' (think thousands of pages of regulations that are broken everyday by facility) and probably aren't purposely doing wrong but have no recourse.

That being said, I've never seen an LTC properly staffed, budgeted and supplied unless it was private pay and didn't accept medicare or medicaid. Maybe you work in one of these magical mythical unicorn filled places, I don't know.

Remember, it's just as easy for anyone to call state or the ombudsman and report the facility for medical negligence.

I don't worry about those things myself. I understand the terms: turning state's evidence, immunity, witness for the prosecution, and defamation tort law.

Don't do anything your career can't handle.

There are 3 RNs that work in this facility. The rest of the nursing staff is composed of LPNs and CNAs. An RN has to be in the building at least 8 hours each day of the week. I work 4 10-hr shifts per week. I am not the DON or the ADON. They are the OTHER 2 RNs. The DON works 5 days a week, 8-hr shifts. An RN has to be there the rest of the days, for at least 8 hours, and these people do need supervision. There are sicker residents in the nursing homes these days... some with PICC lines and other special cases. LPNs have basic training as nurses so I actually take pride in the fact that we can handle some things that other facilities in the "olden days" couldn't handle because we have other staff with more training. I know that you haven't heard of a nursing home supervisor but that doesn't mean that it can't exist or isn't useful. Yes, I'm part of administration but it's not "part of my problem" as I actually go out on the units and participate when I'm not documenting, writing orders for wound care, working on inservices, speaking to family members or residents, etc. I do wound care and staff development training for the CNAs so that they can keep their yearly certifications up. I have many hats that I wear and TRUST ME... I stay busy the entire shift that I'm there. I can't always stomp the halls like I'd like to do. There are unit managers on each unit and they are LPNs. They also work 8-hr shifts. They are there as a resource person. We also have a night nursing supervisor and she works M-F 3-11 shift. She's an LPN and she does admits and helps the other staff, as well. So chalk our facility up to being unique, if you will. NOW you've heard of a nursing home supervisor. Welcome to 2018. ;)

As far as being a hospital nurse who now works in LTC... I started out in a nursing home in 1996-- that was my first job as an RN, thank you very much. :) There were the EXACT same challenges of people not being turned, changed, etc. I didn't think this job was going to be a cake-walk or "easy."

We didn't have special boots back in 1996 for the residents... we had crappy heel protectors. Thankfully, times have changed and we have more assistive devices to help prevent wounds-- like wedges and open-heeled heel protector boots, etc. Getting people to do their jobs as required is not a new challenge in this life/career. It's the same old struggle. I didn't come into this job thinking it was going to be a bed of roses and I'm not frustrated to the point of quitting. I'm THRILLED to be out of hospital nursing after over 20 years of stomping THOSE halls.

As far as legal action against these people, I have no interest in that at this point. I just had the concerns that I listed in my original post... and wondered what people who have been doing this LONGER than me have done (strategies, tactics, etc.) that may have worked/helped motivate people to actually DO their jobs efficiently/correctly.

Our facility has plenty of staff-- more so than is required by the state, actually. We have never run out of supplies to care for the residents properly, and our Administrator allows us to buy extras for some of the special cases that we have had-- wheelchair cushions, foam wedges, large open-heeled heel protectors boots, etc.

And I'm not doing anything that my career can't handle-- no one is getting turned in to the law/BON over any of this at this stage in the game. :)

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Are you the DON of this facility?

Nope. I'm one of 3 RNs that work at the facility. 1) DON 2) ADON 3) RN Supervisor/Wound Care (me). An RN has to be in the facility for at least 8 hours 7 days a week... and since none of use wants to be there 365 days a year... ;) ...

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Thank you for your lengthy reply. Much appreciated.

First, let me be clear that I don't sit in the office and play. :no: I have many hats that I wear at this facility and none of them require playing. I clarified that in another post above that you can read if you wish. I am working on the follow through part and also seeking out the support of this through my Administrator and DON. Apparently things have been happening in this facility a certain way for a long period of time and staff will need to be adjusting to changes that will be implemented to get things to run more smoothly. It's a work in a progress and things aren't going to change overnight.

We had our Quality Assurance meeting yesterday and MY part of it wasn't the greatest... Not like it was for the 4th Quarter last year-- numbers were better as far as wounds went. The only thing that really got accomplished in this last meeting was that 1 person would be designated to do the Admits and assess the skin of those new people to make sure there were no wounds present on admit. That doesn't help me as far as the "every 7 day" skin assessments that I'm supposed to be getting from each LPN. Unfortunately, I cannot always be on the floor-- but I do frequently make rounds on the units. There are unit managers during the day for 8 hours-- an LPN on each unit to help with orders, families, residents, etc. I think we do struggle more on the 3-11 and 11-7 shifts with supervision but there's also a 3-11 LPN who is a supervisor in the building. I implement her help when I can... it is just a never-ending battle (to get people to use the wedges on certain residents, for example). I go in at 5AM and make rounds on the units but have to ask the LPNs who are there from 11-7 to make sure the CNAs are doing their jobs. I can't be there 24/7. No one can.

I agree 100% that I need the follow through and to become more of a hard*** with these people. I do mean business as 1) I've seen who the slackers are and 2) I'm there to be a supervisor AND wound care nurse and 3) these residents deserve the best care that we can provide.

I get to the nursing home every day that I'm there at 5AM... sometimes a bit earlier but usually 5AM. I make rounds on each unit and ask how their night went, if there were any issues... I gather up what skin assessments have been turned in and log them into the computer (I monitor for a 5-week period each month-- there's a 10-day grace period-- so skin assessments have to be turned in every "7-10 days" on each resident, printed out, turned in to me so they can be logged. If there's a skin problem/concern, other than a rash or skin tear, I have to go check it out and write orders for it).

The assignments are done by the Staffing CNA. She takes care of call-ins and all staffing assignments. She's been there 7 years and that's just a 1-woman job and she takes it very seriously. The admits are done by the LPN in charge of her unit... Example: Jane works the 400 hall and has up to 30 residents at any given time. She might get 1-2 admits on her unit. Roger is the unit manager and he will help her with admit orders, etc. She will do the skin assessment on that admit. It's her hall, her resident, her admit. That's how it rolls there. The med nurse is the treatment nurse is the nurse on that hall. She has 12 hours to complete her duties.

Other than the assignment suggestions, because our facility is run a bit differently with already-scheduled assignments for each CNA, LPN, etc., you have given some really good advice and I'm going to copy/paste and save it... as well as implement many suggestions. Thank you! I'm getting not-very-far with my other supervisors so I'm having to utilize other resources and my own ideas right now. I'll get it figured out. I have to!

I don't have any kids and this is 1,000,000% what this is... being a baby-sitter to a bunch of adults. It's sad but it's reality.

I'll organize copies of common policies, F tags, etc. this weekend. Thank you, again.

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I've only done write ups a few times on around 5 people since I've worked there. I was looking at patterns and only recently discovered this "rash" of dressings not being done last week. The write ups were 1) needed and 2) new for these individuals. This only happened last week so time will tell if it "worked" or not. ;)

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Thanks, Davey. I appreciate your comments. I can get choked up when I think of how these folks rely on US to help take the best care possible of them. What if it was THEIR mom or dad or grandma? I just don't understand that lack of empathy for others. Sigh. :(

When I did do the corrective actions, I mentioned the falsification of documentation and the "neglect" that it was to these residents. I can only hope they LISTENED and not only "heard" what I was saying. Do you know that one of the LPNs-- an older lady-- was so upset over the corrective action that I justifiably did on her that she put a soiled dressing in a plastic bag and put it in the top of my wound cart (that is stored in their med room)? She did it, I can only assume, to show that it had an older date on it (and it was a dressing that was to be changed daily)-- she was trying to prove that she's not the only one not doing dressing changes as ordered... But I had to point out to people who had the corrective actions: "We are talking about YOU right now... not anyone else." They are like children, "But what about Bob and Annie and Jenny...??? They aren't doing blah-blah-blah EITHER!!!! What about THEM????" Ugh!

So now I keep the thing locked. There's nothing in that wound card that people need to get. So locked it stays from now on. She was just being passive aggressive and you can bet your butt that I'm going to talk to her about it when I see her again next week. I only see her every other Monday because she's on the opposite rotation of me.

I've read about inservices where they did things like that... with uncomfortable objects or not allowing people to shift positions in their chairs, etc. I think those are brilliant and I will utilize them in the future, for sure. I've had several mandatory inservices since I've worked there... Abuse/Neglect, OSHA, Dementia training, etc. Inservices are new for me and I don't want to always play a video for them. I think the interactive ones are more fun and keep people awake more. ;)

Thank you again for your comments and advice.

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