Mrs. M.

I will be posting a position for a subacute manager soon. Salary will be $90,00-98,000 DOE.

The 5 Star Rating system went into effect today. It starts with your annual survey results, then adds and subracts stars based on your QM data and your staffing. I am also very frustrated with the pressure ulcer information. Our Transitional Care unit specializes in wound care, so we admit many patients with pressure ulcers which we heal very successfully. Unfortunately, it shows up as a bad mark on our facility, because there is no differentiation between "admitted with" and "acquired in facility"

Utilization Review, perhaps?

Bed rails can be very dangerous. The CMS (CDPH) data shows that there were 46 deaths last year related to people basically hanging themselves on their bed rails. Care planning is the key. If the resident uses the rail for mobility or requests that the top rails be left up you are good to go, as long as it's documented.

You need to get the list of approved abbreviations from your hospital. I have struggled with eliminating many of the old standard abbreviations from my routine, but I've had to change because it is a patient safety issue. Better to learn this correctly now than to have to re-learn later.

I sent a CNA home just last week because she was wearing artificial nails. I gave her a copy of the policy, explained why we had such a policy, and told her not to come back until they had been removed. She came back the next day with the nails gone, and not another word was said.

That sounds about right. We run 8:1 on day shift and 12:1 at night (24 beds). Our unit is somewhat unique in that we do have a lot of wounds that come from other hospitals and SNFs (as secondary diagnoses), and we have a dedicated treatment nurse for that purpose on days.

Central California - we start our new RN grads at $34.00/hr.

Congratulations on your new position! At our facility, the TCU is very much like the med/surg units that many of us use to work on. The acuity can be quite high, and the diagnoses are all over the board. It's a great unit to start with, because the length of stay is a little longer so you can learn more from your patients. You will most certainly see diabetes, heart disease, chronic infections, etc. You are likely to have people admitted with significant pressure ulcers, and people who have been non-compliant with their care at home resulting in re-hospitalization.

Our Subacute and Transitional Care units are departments within a hospital system, and we have a career ladder just like the rest of the hospital departments. RNs put together a portfolio of their accomplishments which include any PI studies they have participated in, research, Unit Based Councils, policies they have written or helped write, etc. It doesn't carry over from year to year - the nurses have to reapply each year to show their continued involvement in projects which advance the professional practice of nursing. It's a ton of work, but the rewards (including financial incentives) are worth it.

the immediate answer is you need to have someone else do it or do it yourself. don't let the patient suffer for someone else's poor work ethic. then, as a don, i would expect you to document the situation carefully so that i could go to the cna and get a convincing explanation or proceed with corrective action. there is nothing more frustrating to a director than having a gut feeling that someone isn't doing their job and not being able to get anybody to document what they know.

If you are going to leave anyway, that's all the more reason to go to the DNS. Your co-workers will appreciate you, and the DNS needs to know that she has an ineffective manager. The manager is putting the facility at risk.

Four months ago we began q 2 hour rounds for the 3 P's - Pain, Potty and Position. Both our fall rate and restraint use have decreased significantly. We are also have very few issues with skin integrity.

We have a chaplain who comes through to visit, of course. This resident chooses not to engage in discussions about spirituality. Our Activity Coordinator spends a lot of time with him. He likes trivia games - he's quite intelligent. He watches other movies in addition to the Mediaographic movies. He is learning Spanish using Rosetta Stone software. We have a facility pet that visits him, and some of our staff enjoy going in to talk with him. He is actually more content with his life than a lot of able-bodied people that I know. The only problem is with a few staff members who have major issues with the Mediaography. Even though I've made it clear that they don't have to be involved in putting the films on for him, it bothers them that it is allowed at our facility. Their most recent argument is that if an emergency were to occur in his room they would be exposed to the Mediaography. He has never expressed any interest in child Mediaography. He likes women. A lot.

Exactly. They will be looking for how you have handled things in the past rather than how you would handle a situation in the future. My advice is to think of several situations from you past where you handled very challenging situations with doctors, co-workers, and patients, and reflect on how you handled the situations. This will help you to be able to come up with your example more quickly.

What you are describing sounds pretty much like what our managers do. Don't ever let someone else do your budget if you can avoid it - you are the one who is going to be held accountable for it, so you want to be the one to create and control it!

I have had soooo many applicants fail drug tests. If it comes back positive for a prescription drug, all they have to do is show the current prescription and there is no problem at all. As for the others, it is so much easier to not hire them than to have to go through the suspected substance abuse process and fire them.

We do pre-employment drug screens, but no random screens after hire. However, we have a good "suspected substance abuse" policy which outlines exactly what to do if you think someone is impaired. I suggest that you see if your facility has a similar policy. If so, read it carefully, and if you think someone is impaired, follow the policy exactly. Rumors and "anonymous tips" are for children - have the courage of your convictions. I often refer to "The State" as well - I had never though about the fact that it sounds Communist, but it sure does! I have always thought that employment in general is the perfect example of "Freedom is Slavery".

I love the flexibility of my salaried (exempt) position. Financially I would be better off if I was punching a time clock, but I like not having to worry about about coming and going at exact times, and if I need to leave a little early I don't have to use combo time. It's true that I almost always end up working more than 40 hours a week, but it's nice being responsible for my own time.

Several years ago I worked at a hospital in a rough area of town. We often had drug deals going on in the parking lot, sometimes the "customers" were our patients. Our security officer was a petite woman who was well endowed. One day she saw something going down and was able to get the police there in time to make the arrest. When I saw her later on the unit I said "so I hear you had a big bust today!" You really can't recover from a statement like that.

Great advice, thanks. I've been in nursing leadership for many, many years, but I'm only a year into my LTC experience. It's a whole new ballgame.

Thanks - those are some good suggestions. He is vent dependent and a high quad. He can actually only turn his head in one direction, and only about 45 degrees. The TV is turned so that the back of it is facing the door. The nurses who are supportive of his rights tell me that there is enough lead time on the disc that they can easily leave the room before the movie actually starts. Covering the jackets and numbering the movies would take away one more opportunity for people to be offended. I'm afraid you are right though. What really bothers the staff is just that he is watching the movies, and everything else is just an excuse for not allowing him to do that. The hardest part of this is that I feel like a hypocrite - there is no way I would go into that room while the movie is playing unless it was an emergency. He's very gracious about that towards me - he'll say "Stop!" when he sees me near his room. I think I will take CT Pixie's advice and try to separate the issues. If the staff will document the actual incidents where they feel he is being lewd, then I can deal with those incidents separately from the movie issue. I think that's where we are most vulnerable at this point.

Sexual harassment laws don't protect employees from patients, they protect employees from other employees/authority figures. According to our attorney, the fact that I have informed them that they do not have to put the movie on for him will cover us. There is potential for all of us to overhear things that we don't want to hear, usually it's conversations between family members of the residents! My biggest challenge is trying to get the staff to understand that they aren't responsible for his soul, and moral judgments are just inappropriate in this setting.

I'm going to take a wild guess that you are not a Director in Long-Term Care. If a diabetic patient wants an ice cream, we educate, educate, educate - then give them their ice cream. Smoking is a different situation, because it puts others at risk. Thanks everyone, I appreciate the feedback. He is a very intelligent man, and usually pretty easy going. He knows his Civil Rights, and can quote chapter and verse to any person who questions him. He's actually fairly reasonable in that he readily accepts it when nobody is willing to put the movie on, and will even say "I've got a movie on" when people he doesn't know start to come through the door. My problem is more with my staff than with the resident. I am repulsed by Mediaography personally, but I can't deny the fact that it is legal and he has a right to view it in his home.

I'm wondering if anyone else has dealt with this and what the outcome was. We have a 59 year old quad (quad x 33 years) who likes to watch Mediaographic movies. Since he cannot put the movies on himself, employees have to assist if he's going to watch. Some staff do not mind this at all, but others are outraged that we would allow these movies in a hospital. I have set up a plan so that nobody who is uncomfortable with the movies has to go in to assist him, and a stop sign must be placed on the door whenever he is viewing to alert housekeeping, dietary, etc from walking in on this. The problem is that he is lewd and disrespectful toward the nurses anyway, and some of them feel that the Mediaography is contributing to his attitude. They are probably right, truth be known, but the bottom line is that he is an adult and what he is doing is not illegal. He has no family, so having a relative assist isn't an option. Any advice here?