Can anyone help me understand patient ratios?

[Maremma]

I am a new nurse. I work in a nursing home/rehab facility. I am beginning to think we are definately making huge errors in our facility. I work the full time 3-11 position in a 25 bed hall. It was at one time strictly long term care. It is now a big befuddled mess if you ask me!

They are "converting" my hall supposedly to a cardiac rehab wing. At least that is what I was told we were doing. So far not so much! I am not even sure what cardiac rehab means right now!

This facility has already "shut down" its dementia unit. Yeah they decided it was a good idea to just put all the dementia patients in whatever empty beds were in the other long term halls. (you can imagine all the problems this in itself has created for everyone concerned)

They "upgraded" the old dementia unit to a "higher end" rehab unit. (Much more money for facility) They did add extra staff over there to "meet the demands of the higher paying customers" The aid to patient ratio is about a max of 8 patients per aid and their is a second nurse from 11a- 7p for a 30 bed unit.

Well somehow my hall (now nicknamed "send em all home crying hell hall") has become the "rehab overflow" hall. I still have a few LTC patients, some dementia patients,also hospice and increasingly more "rehab overflow" patients. It is just me the LPN and two aids for these 25 beds.

In a LTC hall only this would be okay with the occasional "bad night". (I have also filled in on those halls and found it to be a vacation even on what THEY call a bad night)

The MAJORITY of my "rehab" patients are NOT cardiac! I think I have only had two in three months. These people are "train wrecks" when they get here. A lot of them I am scared to death because the reality is they should NOT be out of the hospital yet. They are barely stable. They are coming to me still full of staples, G-tubes, wound vacs, wet to dry dressings, trachs, IV medications (which the facility has YET to certify me for so I must run track down either the RN super or someone certified to hang these darn things) Hoyer lifts, fresh amputees, you name it they are sent here.

To make things even more fun they eliminated our unit secretary and dumped her job on us as well. They also refuse to hire an admissions nurse so that is also my job, (assessments, care plans and all) They do not limit WHEN admissions can come nor how many at a time. We LPN's are also responsible for going to the dining rooms at supper to help there and make sure no one chokes etc (really WHO is watching all my patients that are eating in their rooms so they don't choke?) They do not put additional staff on on Fridays AKA "hospital dump day" to help handle all the new admissions that we are going to get slammed with. They do not seem to even screen the new patients at all. SO frequently I am sent "rehab" patients that ALSO have dementia, schizophrenia or bipolar disorder, are NOT stable on their psych meds have multiple behavioral issues, including violence. So I get all kinds of "surprises" thrown at me when I do try to assess them.

When we ask for help we are told to quit complaining. We are lucky here. The aid to patient ratio is 18 to one and each of our aids "only" have 13. I am not even sure what the patient to nurse ratio is but it must be over at least 33 to one because one of our LTC halls has 33 beds and we never got in trouble with the state for that.

So who decided these ratios? Does it matter WHAT TYPE of patients are being put at the ratio of 25 to 1 nurse and 13 to one aid? What about all the patients that require two aids for care and transfers etc? Is there a limit to how many of them can be mixed in with the one assist patients? Is there a limit to how many psych patients or dementia patients a nurse needs to protect the other patients from in one hall? Is there rule that changes the ratios based on the level of care these patients require?

This situation is beyond dangerous for all concerned. It is beyond out of control. The double talk from the higher ups leaves you with your head spinning ever time they yell at you. THEY don't know what to do with the mess they have created is what I have concluded. Someone has to take the blame and I am at the bottom of the totem pole I guess.

Indeed this past week has me looking for another job in another facility. We had a terrible incident happen and the "meeting" with the acting administrator and one of the day time RN supervisors left me in terror of working for these people. I followed protocol for dealing with a dementia patient that was acting behavioral but not violent. She was simply trying to get out of her chair. (my butt would hurt too if I had to sit all day every day in a chair) No biting spitting kicking punching etc. ONLY trying to get up repeatedly. Toileting, taking for brief walks as she could physically tolerate before having to sit from buckling knees, snacks, puzzles etc. She gets routine ativan 2 times on my shift. None on the other shifts. She had a PRN order for ativan as well with a not to exceed in 24 hour period parameter. (if divided into three shifts I am maxed on on my allowed amount for my shift anyway but no RN super would give me a straight answer on whether I am allowed to use PRN or not on my shift due to this) Still we must go through all the non medication interventions before resorting to PRN anyway. SO my patient comes back from supper and is doing the same thing. In 15 minutes she is due for her routine ativan. Began the non medication interventions, toileting, short walk, time for routine, family members freaking out, ask aid that is sitting at desk doing nothing to watch patient until I can get caught up,RN super busy sending someone out to hospital on another hall. Well someone decided to weave her sweater through the back of the chair she was in (physical restraint) while I was dealing with the worked up family member and rushing to give all the meds to all the patients I know have NO patience whatsoever and will also make scene if they do not get them at the exact same time every day.

SO I am being screamed at over and over for not using her PRN ativan. I restate that she had routine on my shift and I did not want to overdose her by giving PRN so close to routine before or after the routine dose. It didn't even have a chance to work yet when I asked the aid to watch her for me. She kept yelling at me and said "Now see we have a problem here! You not using her PRN ativan caused an aid to become frustrated with her and caused her to physically restrain a patient" This is state reportable offense!" "it can cost you your license!" I reiterated that she was not violent in any way, only trying to get up. "She says "I am not telling you to chemically restrain anyone" (REAAALLY? it sure SOUNDS like that is what I am being screamed at for not doing?) I got screamed at for not trusting the aids and screamed at for trusting the aids after all they have a license to and are trained. I got screamed at for taking responsibility and screamed at for NOT dumping responsibility on my RN super. Yeah my head was spinning when I left there. I was on suspension with all three aids that had direct contact with the patient because how can they know it wasn't me that tied her to the chair? REALLY? Does it make an ounce of sense to ask an aid to watch her for me if I was going to tie her to a chair in the first place? The next day I go back for a second interview with the regional DON and am thanked by her for everything I did that got me screamed at the day before by the Acting administrator and RN super.She said she is even shocked that I would do direct care on a patient (toileted her to try to make her comfortable while the aids were still collecting supper trays from the floor) She appreciates that I was trying all non medication interventions. She said she is confident that I did not tie my patient fast to a chair and could come back to work my next scheduled day. The actual administrator was there the second day and said "yeah if you still want to work here". Umm no I do NOT want to still work here. I am scared to death to come to work every single day as it is but I have no choice unless I can find another job. For all I know it is exactly the same everywhere and going to school to be an LPN was the biggest mistake of my life. That is what went through my mind but of course I say nothing.

If there were not so many different type of patients with so many different needs and demands down my hall along with screaming demanding family members that are sure they are the only ones there creating so much chaos every minute of every day this would not have happened in the first place.

[Epic_RN]

Can you go back to school and get your RN? You would have more options as an RN. Like quitting the job you have now.

The only state that has state mandated nurse to patient ratios is California. However, its not all sunshine and roses there. The hospitals have just fired all the ancillary staff to make up for it.

Not sure what you're referring to, my CA hospital has not let any ancillary staff go.....

[Rob72, ASN, RN]

Okay, generally, Esme and I are on the same page, but I would like to (perhaps) expand on what I read.

Yes, patient ratios are "recommended" by Jack-O, Nerds In Hiding, and Morbidity and Mortality, 'scuse me, "Medicare and Medicade". These ratios, however, are subjective, as noted.

The ratios under which many practice are determined by overhead/"clients"/nurses. Why? Because there is no ICD billable unit for nursing care, ergo, the physical facility takes precedence over nursing staff. Nurses are a dime-a-dozen and easily replaced. The "customer service" model of tile floors, coffee bars, etc., are used to make up for questionable care-practices. It works, as long as there aren't too many Sentinel Events.

If we want to change these standards, "someone" needs to bring a class-action suit, probably against JCAHO, substantiating patient endangerment by incompetent policy direction(i.e., allowing MBAs undue influence in care-delivery).

[Maremma]

Well how does "someone" bring a class action suite against JCAHO? Why hasn't "someone" already started this process? I am going to assume that nurse's have been attempting to get them to do this with no success that you are saying we need a class action suite to motivate them to action. Is that correct?

[Esme12, ASN, BSN, RN]

Okay, generally, Esme and I are on the same page, but I would like to (perhaps) expand on what I read.

Yes, patient ratios are "recommended" by Jack-O, Nerds In Hiding, and Morbidity and Mortality, 'scuse me, "Medicare and Medicaid". These ratios, however, are subjective, as noted.

The ratios under which many practice are determined by overhead/"clients"/nurses. Why? Because there is no ICD billable unit for nursing care, ergo, the physical facility takes precedence over nursing staff. Nurses are a dime-a-dozen and easily replaced. The "customer service" model of tile floors, coffee bars, etc., are used to make up for questionable care-practices. It works, as long as there aren't too many Sentinel Events.

If we want to change these standards, "someone" needs to bring a class-action suit, probably against JCAHO, substantiating patient endangerment by incompetent policy direction(i.e., allowing MBAs undue influence in care-delivery).

Right again.....and we all know that there isn't a facility that will say "we feel this isn't enough, we'll add more nurses" These are bare minimum requirements/recommendations....the facilities can change them but not go beneath them. YOu are right as long as they aren't above the radar and in trouble......everyone goes on their merry ways.

I'm not sure who would be the brunt of a class action suit The JC (as they now prefer to be called, again) but it it also the government that would be the primary defendant as they "set the standards" so to speak.

Why hasn't there been a law suit I hear you ask? You would be fighting the government and that is frowned upon....besides anyone who bucks the system has learned. You want to work in this town? You keep your opinions to yourself.

[Maremma]

Indeed I understand that. I understand it is "the way it is" in just about every arena not just nursing. I was just wondering if some one had already "just had enough now" and attempted something like this. It seems to me if California now has new laws limiting the ratios to safer numbers someone there must have "gotten a bee in their bonnet" and lit a fire under some government officials butts and made the fire hot enough to move them to action, it CAN be done other places too.

I am not sure exactly what the laws are in these other states but whoever got that bee in their bonnet in California seems to have set some type of ball in motion in 11 other states too.

Nurse-To-Patient Ratios: The Science And The Controversy | Healthcare Hacks

I guess that person didn't know the rule about not bucking the system. That or took a beating for it and rather than giving up and staying down when they knocked them down came back up swinging and hit a weak spot in "the machine that enslaves us all" causing it to shift gears. They found the Achilles heal I suppose.

[TheCommuter, BSN, RN]

Well isn't that so nice of California health care facilities!

The legally-mandated nurse/patient ratios only apply to California acute care hospitals. Skilled nursing facilities and nursing homes in the state of California are not included. Therefore, a nurse in a skilled nursing facility in CA could have 30, 40, 50, or more residents.

[Maremma]

Well at least what has happened in California is a start anyway.

It would be nice to hear from people working in the LTC units in California that have been there across the line. Like the long standing nurse's in my facility. They saw the horrible trickle down affect of cutting hospital staff. The people coming to us from them were in far worse shape than before the hospitals cut the nursing staff.

I wonder if the LTC nurse's are seeing the opposite affect since they enacted the new laws out there. Are the patients being handed off to "rehab" units and LTC units in more stable condition? Further along in their healing of injuries?

I understand that insurance cut offs are also responsible for some of the huge problems I am seeing coming in to us. I am directly told by the patients or family members that the reason they are at my facility is because insurance forced them to move from hospitals to us before they were actually ready to come to us.

I am to new and do not understand enough of how things work yet but I do have the good sense to know I need to be afraid. recently I had a patient come to me that made my head spin. I was so dumbfounded that our facility would even "accept" this patient.

We were nowhere near equipped to deal with her in my mind anyway. She belonged in burn unit somewhere if you asked me. We did not have anything "ready" to even deal with her pain much less skin graft care etc. It seemed they took no thought whatsoever to the fact that they were not only taking a patient that really should not be here in the first place but then they bring her into a hall with an LPN with less than a years experience working under an RN super that is also a new nurse with NO floor experience. They ALSO thought it would "work out just fine" to ALSO admit three other new patients to the same hall in the same shift two of which were dementia rehab with uncontrolled behaviors.

Even if the law changed would "only" help out the hospital nurses with lower patient ratios I can't help but believe it would still benefit the rest of us too. You know like they would then have more time to actually CALL us and give us a good report ahead of time so we actually knew WHEN they were coming, what exactly to expect when they get there etc. I also think the patients would be more stable when they get to us.

Out of those four new admits I got report called to me before the patient actually came on ONE of them.That report was on the burn patient with all the broken bones and a pre existing anxiety disorder. It was called in to the day shift nurse and I never even spoke to the reporting nurse to ask any questions. I got a half fast report from day shift that just wanted to go home asap. Yeah and told things were already in motion for her but really weren't. I was not even told this patient ad burns and skin grafts in the report I got! I was told "car accident victim, broken ribs, both hips, one thigh, one ankle, pain pump prescribed, PICC team on the way, xray set up to check placement, pump will be here on first run. (umm no it wasn't. They dropped the ball and never got a narc script for it so of course pharmacy can't send it)

TWO I got report after they were already rolling down the hall and one NO report at all! We had to call and ask for report got the run around and no one called us back for three hours!. yea even as a LTC nurse I still want to see more nurses per patient in the hospitals.