Overwhelmed on a Rehab Unit--Mgmt No Help

Valerie Salva, BSN, RN · Sep 29, 2008

((((Emma))))

Been there, done that. I feel for you. Sub-acute rehab is one of the most demanding areas of nursing, in my experience.

With most of your admin having no medical background, and no clue, I honestly don't think it would do any good to try and talk to them. If you do, you'll probably do it all alone, and just be labled as a wave-maker. If your co-workers are so intimidated that they clock out, then continue working, I can't see any of them standing up to mgmt with you- re: working conditions and staffing.

Mgmt already knows that nurses typically last only three months there, yet they still don't have a clue.

Years ago, I had an administrator at a rehab unit who was one of the "Corporate Carls" you describe. He called me into a pt's room, pointed at the foley bag hanging on the bed and said "There's urine in there!"

If I were you, I'd look for another job.

BradleyRN · Sep 29, 2008

I am surprised that anyone even stays three months under these conditions. There are no mandated nurse/pt ratios for LTC, but the most you should ever have on a skilled unit is twenty patients. If you are making med errors and missing treatments, then it is your responsibility to QUIT before you hurt someone. They are forcing you to neglect people with this insane patient load, but if you allow it to continue, then you are accepting neglecting sick people as the "norm", and the neglect rests solely on your shoulders. It is not the norm! It is unlikely you could effect a change in the obviously greedy administration for which you work, so i can only recommend that you quit at once. They only want the sorriest of nurses, which you are not among, or you wouldnt be here sharing your disgust. Complaining about a patient wanting a half a Vicodin or to be disimpacted is a symptom. Im sure you never thought youd be angry inside for a pt wanting a Vicodin, but here you are. Get out before this symptom becomes a disease! Good luck...:)

CoffeeRTC, BSN, RN · Sep 29, 2008

I'm surprised. Staff turnover like that is normally more expensive than trying to keep a few staff around.

It is absurd what they are trying to to. I work mostly LTC with a good bit of skilled and LTC mix. I get freaked when I have over 8 diabetics for my 22 residents. wow.

Calling the state probably wont help. As a pp stated...there are guiides but no actual laws. Do you have a corporate complince hotline? That would be the place to start.

Do NOT PUNCH OUT to chart. Yeah...I yelled that. Don't

NurseExec · Sep 29, 2008

You talk about the administrator in your post but you don't mention if you've had a conversation with your DON about this. If not, you should.

BradleyRN · Sep 29, 2008

You talk about the administrator in your post but you don't mention if you've had a conversation with your DON about this. If not, you should.

If the DON hasnt gotten the picture with nurses only lasting 3 months before quitting, then someone needs to start turning that DON q2h and check for brainwaves. Any DON who doesnt realize this assignment is unsafe is either an idiot or getting paid to pretend like they are.

Sean 91 · Sep 29, 2008

Come (back) to the hospital setting. 1:5-6 ratios. Management is generally no help at the hospital, either. But at least you'd be working with other nurses--getting support and providing it in turn.

noc4senuf · Sep 29, 2008

There may not be mandated ratios for nurses but, there is a requirement of how many hours per day each resident receive of nursing care.

My TCU or rehab unit is 28 beds. That means 2 nurses on days and evenings, one on nocs. I also have a nurse manager that pitches in and works many hours on the floor. What you have described is totally unethical for the amount of money your residents pay to be there.

NurseKatie08, MSN · Sep 29, 2008

I'm currently working in a LTC facility in the Subacute/Rehab unit. I've been there 4 months. When I hired on, they said when the census hit 24, there would be 2 nurses on.
Well, we're at 29. We have 30 beds. I have 21 diabetics, almost all with sliding scale insulins to treat. And...I have to be in the dining room when the trays arrive (requirement by state).
I am finding it IMPOSSIBLE, as are my coworkers, to get there on time. I have dementia patients (apparently they just want to fill beds and don't care if it's a subacute unit), and they wander...so finding half of them to get their fingerstick done is also a chore.
I'm running to the point of sweat pouring off my body. I don't mind being busy; in fact I love the challenge and love running. But...I don't like being overwhelmed. I don't like running so hard and still not managing to get the tasks done on time. And it's not just me, the other nurses have expressed this to our unit manager, who is going to bat for us at some point this week.
The bottom line is: money. They have a marketing liason who gets these people recruited from discharge planners at the hospital with NO medical background. She waltzes in and states "You have 2 new admissions coming this shift." and smiles, heels clicking, walking down the hallway. She has no idea how difficult it is to get our work done, plus do quick head to toe assessments, get orders verified, get meds ordered, on top of the workload we already have.
The nursing home administrator has a background in business. She apparently "went to nursing school but didn't do clinicals." She has NEVER taken the time to assess what happens on our unit. She says, "Halls A and B have 30 patients and they have only one nurse." But....these people are long term care patients. I've worked those units, and the staff anticipate their needs (as they are demented and don't use their call lights). So, even though there are 30, there are only 2 diabetics, and they are not alert and oriented. They also only have about one or two patients that request PRN drugs.
My unit is diabetic and PRN hell. I can offer a PRN drug to a patient while I give them their scheduled meds, and they'll say "No. I don't need it now." (Which is fine). But then in the middle of getting 21 fingersticks, I'll have a patient ask for a suppository. Then an enema. Then 1/2 a vicodin. Then ask for me to come in and "remove my impaction". Then the phone ringing nonstop. Families of all of these patients calling asking how their aunt is. Families who are there who are demanding a cup of ice ...NOW.
I love what I do. And none of the nurses are willing to stick their heads out and make a stand. Corporate walks through and grabs the Vanco I.V. off my med cart as I am getting ready to walk into that patient's room. He has it in his hands and says, "Why is this here? Should I take it?" I reply, "If you have an infection and think you need it." He says, "Perhaps I'll report it to your D.O.N.". ****This is frustrating beyond all frustrating***** These Corporate Carls (I call them), come in, intimidate (or try to), and don't listen to the real issues. Don't understand that I'm going to put the I.V. Vanco on my cart as opposed to walk all the way back to the med room, if I'm getting ready to walk into the patient's room. There's no where to put it in my med cart.
The last Corporate Carl that walked in asked, "why isn't there a sign that says 'Med Room' on this door?". I about died. How about we advertise, in neon lights, "Narcs Found Here!!". I politely looked at him, ignoring his (what I felt to be ridiculous question), and said, "While you are here, would it be possible to assess the need for additional nursing staff?" He said, "You can ask me anything. It doesn't mean it will be honored." (while laughing).
It is a "for profit" organization. Is this the problem? Or is it the same everywhere, for all of us nurses? Have I seriously got a chance at getting someone somewhere to listen to our plea for help? Can I call the state? Is there a staff/patient ratio requirement on a LTC subacute unit? How do I find out?
I don't want to quit this job. I love what I do, but it has to be made POSSIBLE to get the work done safely for patients, and safely for our licenses.
Nurses are literally clocking out and going back to do their charting (No overtime allowed) to cover their butts. It seems that they will open up amongst each other, but have fear to make a stand. Maybe they know it will do no good.
I'm told by one of the attendings who comes in, "Nurses last about 3 months and then fly." I'm also aware that it's cheaper to have high turnover in staff than to retain staff and pay out benefits.
I'm feeling very unappreciated. Errors are unavoidable with the high demand on this unit. A missed med here, a missed treatment there....I see it everyday.
None of us want to quit....we just want to be able to work safely.
Any suggestions? I'm running out of hope....
Thank you.
Emma

Emma, I would run fast and not look back. This job is putting your license at risk.

I am a new grad on a sub-acute/rehab unit with an 11:1 ratio when we are full. (2 nurses on on days & eves, 1 on at night). I do not see how I could possibly safely care for more than 11 patients, which is hard enough as it is.

21 diabetics? And no other nurses to help?

Management doesn't seem to care, in your case. I would put in your notice & find another job that isn't going to force you & your patients into an unsafe situation. Seems like they just want to fill the beds.

bossynurse101 · Sep 30, 2008

Emma

Having a bit of exp in SNF admin I can tell you that unless your DON is alert and oriented x three (which it doesnt sound like she is or wants to be) you are fighting an uphill battle. The administrators job is to oversee the dept heads to ensure that they are running their depts. Very few have a nsg background as business experience is more helpful for what they are hired to do which is to keep the place running AND try to be in the black. Trust me, with the Medicaid cuts, pharmacy costs, lack of HMO pmts, transportation costs, food, linen, etc etc, it is not as easy as you think. Yes, it is a business, and something has to pay the bills. That something is the Medicare rehab pts. Period. The mktg liaison's job is to get as many as possible, period. No, she is not concerned with your pt load, the type of pts, etc. - that is you Unit Mgrs job - to advocate and communicate to mgt that safe nsg care is not possible with the level of acuity and the high pt to nurse ratio you currently have. After that, the DON shd be pulling in more staff through agency of by way of the nurse mgrs if possible. Sometimes, hiring an admission nurse is appropriate in a facility that has a high number of admissions. Unfortunately, most of the Corp Clydes or whatever you call them, do not have any clinical know how or experience to understand or help you. There shd be a nurse consultant tho, - they are the direct supervisor of the DON, and they WILL listen, especially if you can show them the turnover. Turnover is costly, and bad for business. Calling the state usually only makes things worse also. Most surveyors great at reciting policy and procedure, but the majority havent worked the floor in years and years, and will just add more paperwork to your already overloaded pen. The nurse pt ratios in Fla include the wound care nurse, restorative nurse, etc. - so those numbers are very construed. Best advice? Run! If you can not get any resolve, it is not worth risking your license. These pts are many times still very unstable, and need to be assessed and monitored in at least a half way decent manner. I have seen pts that were supposed to go home, but did not (well - they technically went "home") due to lack of adequate staffing. There are other rehabs with great mgt, that will more than support your desire to give good pt care. You sound like an excellent nurse, one that these pts need. Dont give up and throw the baby out with the bath water. Find a place that WILL appreciate your talent, they ARE out there. Then, after you get some more time, then you can go to the mgt side, and use your experience to make a difference. I did.

Best of luck to you, let us know what happens

lindarn · Sep 30, 2008

Emma
Having a bit of exp in SNF admin I can tell you that unless your DON is alert and oriented x three (which it doesnt sound like she is or wants to be) you are fighting an uphill battle. The administrators job is to oversee the dept heads to ensure that they are running their depts. Very few have a nsg background as business experience is more helpful for what they are hired to do which is to keep the place running AND try to be in the black. Trust me, with the Medicaid cuts, pharmacy costs, lack of HMO pmts, transportation costs, food, linen, etc etc, it is not as easy as you think. Yes, it is a business, and something has to pay the bills. That something is the Medicare rehab pts. Period. The mktg liaison's job is to get as many as possible, period. No, she is not concerned with your pt load, the type of pts, etc. - that is you Unit Mgrs job - to advocate and communicate to mgt that safe nsg care is not possible with the level of acuity and the high pt to nurse ratio you currently have. After that, the DON shd be pulling in more staff through agency of by way of the nurse mgrs if possible. Sometimes, hiring an admission nurse is appropriate in a facility that has a high number of admissions. Unfortunately, most of the Corp Clydes or whatever you call them, do not have any clinical know how or experience to understand or help you. There shd be a nurse consultant tho, - they are the direct supervisor of the DON, and they WILL listen, especially if you can show them the turnover. Turnover is costly, and bad for business. Calling the state usually only makes things worse also. Most surveyors great at reciting policy and procedure, but the majority havent worked the floor in years and years, and will just add more paperwork to your already overloaded pen. The nurse pt ratios in Fla include the wound care nurse, restorative nurse, etc. - so those numbers are very construed. Best advice? Run! If you can not get any resolve, it is not worth risking your license. These pts are many times still very unstable, and need to be assessed and monitored in at least a half way decent manner. I have seen pts that were supposed to go home, but did not (well - they technically went "home") due to lack of adequate staffing. There are other rehabs with great mgt, that will more than support your desire to give good pt care. You sound like an excellent nurse, one that these pts need. Dont give up and throw the baby out with the bath water. Find a place that WILL appreciate your talent, they ARE out there. Then, after you get some more time, then you can go to the mgt side, and use your experience to make a difference. I did.
Best of luck to you, let us know what happens

After you run, (and find another job), I would call the NLRB and report that they refuse to pay you OT to finish your work. They are not keen on workers being told to sign out to finish their work. You are also not covered under workmans comp if you get hurt while you are working off of the clock.

Lindarn, RN ,BSN, CCRN

Spokane, Washington

TheCommuter, BSN, RN · Sep 30, 2008

A poorly staffed LTC subacute unit equates to sheer hell on earth.

I worked subacute at a nursing home, and the patients were just as acute as what you'd find on a hospital med/surg unit. I cared for middle-aged and elderly residents who were recovering from laminectomies, kyphoplasties, knee and hip replacements, thromboembolectomies, hysterectomies, amputations, debility, cancer, acute MIs, acute CVAs, uncontrolled diabetes, CHF exacerbation, and a host of other ailments.

I typically had 34 of these types of patients with a medication aide, or 17 patients without a med aide. I had to get out after I started experiencing physical symptoms of stress such as chest pains, palpitations, perspiration, anxiety, and overall feelings of dread when I walked onto the unit.