fromtheheartRN

Interesting. What about cases that involve discrepancies with SOC functional status? In order to improve STAR ratings and reimbursement?

Ha! I have been doing OASIS for six plus years. All the sudden, in last six months, when my company's STAR ratings go low, I have been doing EVERYTHING wrong! Get tons of returned corrections that I do not agree with and have never gotten before. Rating people "dependent" in toileting ONLY because they rate their pain 7/10. Even had to go through "remedial training," though I am a preceptor. Verges on Medicare fraud, IMO. Trying to make patients look like they are worse in the SOC, only to get higher STAR ratings, or more pay. I can't tell which. Possibly both. Depends on the company, I guess. Frankly, I am very disappointed in mine. As is apparent. Looking elsewhere.

It certainly wasn't what I signed up for. Worse than the hospital schedule now. Used to be good and flexible when I started. Things have definitely changed. I document sometimes until 9 PM almost every night and wake at 4 AM just to manage case management, write notes to call the MD offices when they open, make sure I don't miss anything. Geesh. No Clinical Manager support for weekend emergencies either. They used to go out in case of emergency. Not any more. They call the patient and tell them to go to ER. WTH? We are supposed to be preventing that! I am actively looking for a better opportunity.

I have worked for my current employer for over 6 years. Started out being guaranteed salary with expectation of obtaining at least a certain amount of points. Expectation was ONE Saturday a month and ONE Sunday every two months, rotation of on call for evenings seven nights in a row every seven weeks. Many changes have driven the company to needing us to be on call from Fri eve to Mon morning twice in a seven week period. Effectively working more than one weekend a month. The weekends are not strictly for "on call" anymore. We generally have a FULL schedule for revisits , SOC's and ROC's. PLUS the PRN's for any emergency visits. We have been told that any weekend revisit (for whatever reason), will not be covered by the scheduled weekend nurse anymore, beginning immediately, and any revisit needed will need to be covered by the RN on the case. This means that if QOD or QD wound care is required, we will be forced to work 6 or 7 days a week, EVERY week! How can this be legal? They, supposedly, tried to hire a Baylor nurse, but were not successful (for at least the last four years, I am told). We are no longer guaranteed salary, we are pay per visit. I love the company, but am fairly burned out working so many weekends to begin with, and now this new requirement will tip me over the edge. I believe that if a wound REQUIRES more frequent changes (per best practice) we are obliged to provide it per MD order, but shouldn't require the RN to work his/her otherwise scheduled says off. If my week was somehow slow, I don't mind doing the weekend visits. But if I already worked 50 hours and seeing 30 for the week, I definitely have a problem with it. This new change was decided by non clinical office people, BTW. Again, can this be legal?

Yep--cover your ass The way it relates to tests is mainly when an MD orders them for reason CYA only.

I have been an RN for three + years. At the same hospital-same floor since graduation. I love bedside nursing and am always looking for ways to grow and learn. I am certified in my specialty and I am a relief charge for our 40 bed unit. I have always prided myself on good relationships with my colleagues, and have been commended by same as someone they can count on to help whenever someone has a pt. emergency or just when a nurse gets over-loaded. I am known to be calm and able to get things done. I frequently get personal notes from the hospital nursing director telling me that I am a valued member of the staff because of various reasons (patient comments, my certification, and fellow staff comments, etc). I volunteered to go to nightshift for the summer last year because they didn't have a charge for Wed nights--as well as our part-time charge calling off most of the time. In other words, I did them a favor. I also do a nightshift occasionally when they are short. This has been voluntary on my part. I have even volunteered to go home early on days so I could cover for an unexpected shortage the same night. Where am I going with this? About six-seven months ago, I decided that I needed a change--more specifically in days of work. Due to family stuff, I wanted to find a position that would allow me to be home every weekend. I informed the director of our floor that I would be looking at opportunities. They seemed (at that time) to be genuinely supportive of me. I have had two interviews since (I have been very picky on types of positions), but did not get hired. Then came an opportunity to NOT leave my hospital--a position that sounded absolutely PERFECT for me! I was excited about it-and very confident about landing it. I emailed my director to let them know. The next day I was on the floor, I was called into the office. Door shut, and was asked if I have been 'stressed lately.' The conversation that followed had me in tears. I was told that I am not good at organizing while in the charge position, I cannot handle emergencies effectively, I over-utilize techs, and generally do not seem to know things that I should know. Okay, I am not infallible. I admit that sometimes I do not know EVERYTHING about all 40 patients, and that I have not been able to get a system down when I am charge during the week. But, I haven't been charge very often--maybe 6 times in the last 6 months. She disagreed--but I wasn't going to argue at that point (I have since looked it up--and I am right about how many times). Anyway, she basically said that I wouldn't be able to do the job because of all these (faults) I have. And, oh BTW, we recently had 4 of our very strong RN's leave for other opportunities and there just isn't anyone on staff right now that is ready/willing to take on the charge role to take my place. And we are short staffed. I recently got placed in my own weekend as charge--so they would be in a jam if I left. I left the office in tears--could NOT believe what I was hearing. So my question is: When I go to my next interviews, how do I explain to them that I do not want them to contact my current employer? And, should I call the other places back who did interview me and ask them about how my references were? I know it is illegal for an employer to ask anything more than absenteeism and "would you hire this person back?" But we all know in the real world that this is not the case. Right now I feel unsupported and manipulated and generally want to give my 2 weeks right now--job or no job. I won't do that, but that's how I feel. Please advise.

RAD = Reactive Airway Disease (newer umbrella term for asthma/COPD) OK--What is CYA? -regarding tests.

I was just mentioning to hubby last night that I needed a new scope--I have severe tinnitus AND hearing loss (result of job in a former life). I have been using a Master Cardiology-which has served me well until lately-I guess my hearing loss is getting worse-right along with the tinnitus. I went online right after reading the posts--the 3000 is on sale at stethoscope dot com. Hopefully I will be able to hear those faint rales and murmurs again SOON!

Need more feedback, please

I had another colleague tell me about a situation, and I'd like some feedback--good-bad-indifferent--I'm open. The nurse was called into the unit director's office, handed some EKG strips, and two regular, common meds (not narcs--or even a med that would be wanted by anyone seeking drugs--OTC, inexpensive stuff). The director said, "These were found on the top shelf of the area you were working this day. Can you tell me about them?" Of course leaving meds out is never right, but the nurse stated that he/she would have placed them in a pt med drawer. The strips were his/hers, but were not placed in the chart because the CNA that day already pulled strips and placed those in the chart (nurse's explanation). They were 'extra.' Both the strips and the meds were found in an area that not just anyone would see--unless they were looking. The nurse admitted to probably leaving the strips there-but not the meds. My question/concern is: if I were deep cleaning and found these items, I would have returned the meds to the pharm, and would have brought the strips to the ward clerk to be given to medical records (if the patient/s were no longer there). So we are both wondering--why would somebody (presumably) take these benign items to the director and ask that she follow it up? Maybe because the director was concerned that if the nurse left these there, he/she could also leave narcs out as well? I argue that, because everyone knows that narcs MUST be accounted for-and you could LOSE YOUR JOB if any of them were traced to you--and they were not given. Sounds petty to me, and smells bad of someone out to bring trouble for the nurse-or ANY nurse-in question. This is one of our very BEST nurses! While I am not saying that leaving stuff out is OK, but why would someone make a huge stink about it? I mean, come on! They weren't narcs! And a simple look at the chart could have shown that there were strips posted already. Neither item was in a place that could be readily seen by anyone--so while I know that it's bad for JHACO, the charts are always MORE available. And, incidentally, the admin also said, "Pulling meds from the PIXUS and not giving them is 'creating a fraudulent charge' for the pt." Made it sound, to this nurse in question, like he/she had committed a crime, which she/he could be severely punished for. As a matter of fact, a nurse was fired about 3 months ago for some pretty shady sounding accusations. She had worked there as staff, charge, and house supervisor for about 20 years. Hard worker, diligent, and liked a great deal by everyone. Also..and I need to find this out, I believe that a patient is ONLY charged for meds that are documented as 'given'-not simply 'checked out' from the unit PIXUS. If true, then that statement would have been used as a scare tactic only--why? To document 'a problem'?' Don't get me wrong, I do not think the nurse's actions were OK-by any means, it just smells funny. Sure, the director was right in 'following up,' but was it necessary to launch a 'full investigation?' What do you think?

I was put in charge of Nurses Week celebration on our unit. I am up for the fun, but I need ideas. I have some myself, but I always let my small ones turn into giant undertakings! Is there anyone here who enjoyed a memorable celebration on their units? I would appreciate any ideas that you can share. We have about a hundred employees...60 are RNs. I would like to include everyone in some way...including the Unit Sec's. We work 12's (7-7), and need to get something together that would work with both shifts. I am not even sure if my director will allow a budget for me (ice cream social, maybe some small gifts for a drawing??) I want to make it special....this will be our first celebration of it's kind!!! Thanks for your help!

crump: verb: In ambulance jargon, to die on the way to the hospital, has been used to describe computer crashes in hospitals too. Example: The driver is hurt pretty bad, he'll probably crump on the way.

CVA= cerebral vascular accident SAH= secretion of antidiuretic hormone ICH= intracranial hemorrhage IICP= increased intracranial pressure

I agree with Tazzi. The ER I worked in prior to my current job did exactly that. It is a huge task to take on when you are attempting to show and convince that adding a float nurse will improve patient safety as well as be cost effective at the same time. Unfortunately, managers MUST look at the latter. Pt safety (in a perfect world) SHOULD come first, but the reality is the financial bottom line. Things to consider including: What is the turn over rate? How much does it cost to train a new RN in your ER? How many sick calls? How many injuries and cost of lost time from work due to on the job injuries--directly or indirectly resulting from a heavy workload? Of course include the Pt safety aspect, but the holder of the purse strings will be looking at the cost first. Make your case very strong...something that they just can't refuse. You need to show either no increase in cost long term or even a reduction in cost. Look for studies in journal articles. Talk to RNs in other ERs and find out how they made the change and what the impact has been (turnover, moral, sick calls, etc). You might consider talking with a dept manager about how they financially justified adding an additional position. If you can present a solid case WITH verifiable support to back it, it will not be easy for them to refuse. I would definately enlist and delegate every staff member you are able to who cares about your staffing (probably everyone?). I wouldn't attempt it on your own. With a lot of thought, much planning, and ample researching, you are bound to succeed. And to sum up Tazzi's thoughts...keep it professional. I applaud your efforts and the willingness to step up and initiate change! Good luck!

Thank you! Perfect---I do not know how I missed these resources on aacn! MUCH help!

I posted this request in Cardiac Nursing, but no replies yet. Also no threads show up when I search. I would appreciate any help with this subspecialty exam--I am taking it soon! Have the study CD and the blueprint. I am reading my med-surg book, looking through CC journals, and basic searches online. Anyone taken this exam that can offer suggestions? Much appreciated!

This "break issue" is NOT just ER! It is part of the nursing culture. Getting a lunch break on my floor is the EXCEPTION and not the rule. And things will NOT change if we all run around (and ourselves into the ground) and keep taking it with the smile and a "good attitude." It takes action...and a strong UNION. They are VERY rare, but I actually LOVE days when I can be caught up enough to offer my assistance to my neighboring nurse--or any other nurse on the floor for that matter--who has a heavier assignment so they can get a lunch break in. I love it because it makes someone else's days a little less stressful, they are thankful, and it is what makes us all feel like we are a team. But, like I said, those days are VERY rare. These are the days when we are staffed fully with a 3:1 ratio and float techs. This is the matrix we are SUPPOSED to follow!!! But when staffing is low...and/or the hospital is near divert, the matrix is thrown out the window. IT IS A STAFFING ISSUE AND NURSING CULTURE! In the ER, it can be easily solved with a designated float RN to cover all lunch breaks. I worked in an ER previously, and that is exactly how they solved the very same problem...successfully and permanantly. But then again, the hospital was a "not for profit" Catholic hospital with a very good union. It also helped that the director went to bat and fought for her nurses to get it changed.

Also, I find it very helpful if I ask the ER RN--or the ER Charge if it would be possible to at least get a patient admitting history prior to floor transfer. Sometimes we are lucky enough to get this if the ER has a "resource RN" hanging out down there-for that reason. I can assure everyone that us floor nurses are eternally thankful if this is possible. Sometimes not, but it is VERY appreciated if it is.

I am a recently new charge nurse on a tele floor. What an eye-opener it has been! I will try to give a few reasons about the "magical shift change influx of admits." AMH, we have a bed board where we can see each pt who is waiting for a bed in the ER-and for how long. Our shifts run from 7-7 on our floor, 3-3 on ICU and they are quite variable in ER. We are a 40 bed unit (quite large), and our staffing matrix is 10 and 4 for all 40 beds during night shift (in a perfect world). 13 and 4 for days. These numbers INCLUDE the Charge. Typically, and because of RN shortage, we only have 5 RNs scheduled and 2 techs. So, IF we do not get any sick calls, AND we get a minimum of 5 RN's from float or agency, AND two techs from float, we can bed to full capacity. A majority of our DC's happen between noon and 3pm. Night shift can call off (without penalty) up until 430pm. Staffing cannot give us a number of floats or agency RN's until at least 5pm. So by the time we can finally ascertain exactly how many beds we can fill, it is probably 530 or so. But, then again, if the hospital is in danger of diverting because of staffing issues "But what do you mean we can't bed these people? There are half a dozen beds empty!!!" The answer most often is (from the HS) "Bed them anyway. The Charge can take an assignment, and the floor RNs can take 7 each." THIS IS IN TELEMETRY! As a new dayshift charge, I am, of course, reluctant to fill em all up. The first day I was charge, I was being pressured into doing just that. In one ear, I was hearing, "Bed to the staffing matrix!!" In the other ear, "Who cares about the ratio? The hospital is about to go to divert! BED!" I bedded 6 patients at 630 (still being very mindfull about acuity). OMG! I thought every floor RN and the charge was going to strangle me the next morning! Also, we wait to see if some of the CP-ers rule out in the ER with a stress test. I know that some of this is off-subject, but in short, the "magical shift change admits" has more to do with staffing issues and other logistics than with ER or floor RN "holding." And, I learned my lesson. When the HS comes around near end of shift (630), and brings up her bed board on the puter screen, I take a list from 'her priorities.' I say, "No, I will take care of it," and walk away when she asks if I want her to bed them for me. I continue with my final rounds and I take this list and give it to the oncoming charge at 645. Maybe this is wrong to do, but this way, the HS has done her job of communication, and I haven't caused chaos for either shift at shift change that can last the entire next twelve hours and sometimes into the day. Cop out? No--I am simply supporting our floor nurses--and the night shift charge can regulate and delegate according to their needs. I will never dump on night shift again! Increased stress and workload translates into decreased patient safety. And THAT is the bottom line.

Too funny! Thanks for the chuckle!

Yeah, me too. I had 6 on Saturday. DC'd 4 (two were SNF's). Two new admits -so really 8 total. Ended with three and took my tech to be a sitter with one of the new ones. (see prev post Pt #1).

Fifty or less? Impossible (my keyboard not allowing me to use forward slash) 1) ETOH 6mg ativan Q2h not touching DTs. 4 IV infilt. Two pulled out. Wrist restraints applied. PICC team too busy. CIWA Q1H now. 2) Nice man need to ready for cath lab-abnml echo. DM. 3) Freq flyer prev fired me yr ago for not giving pain meds upon walking into unit straight from md office-no orders yet-would not let me get a BP. Apparently she does not remember me. Asking for 4mg dilaudid Q4 (watches clock) and phenergan Q6. Zoned out. Sneaking caramel corn and water when supposed to be NPO for US. Spilled chocolate ice cream (I canceled US) all over the front of her night shirt from home. UGH! 4) CHF-COPD-DM UNMOTIVATED. S-P pacer Day 5. Refuses SNF (will not be able to get her daily glass of Bourbon). Unsafe to go home. Refuses PT. Whines when I make her stay in chair for meals. Hates the food. Refuses the food. Diarrhea and incontinent of urine after Bumex. Nice family though. 5) VERY nice female CP S-P stent and S-P repair for dissected stent resulting in AMI. Husband recent deceased (on our unit). VERY nice family-knows everyone on floor. Increased O2 needs PAO2 = 50. 5 pm- tech taken from me to be unit sec. Posey applied to #1. #1 to CCU because of need for ativan gtt. Decided at 645 pm. Report to CCU RN at 715. Night charge (Pain in orifice) demands that we transfer him NOW! (though stable). Night RN has not come to me for updates yet (shift change between 7-730). Night RN decides she is going with transport (though NOT necessary-Pt is stable and gtt not started yet). I am fighting a cold-should not have gone to work (but we are SO SHORT!). Wearing a mask all day to protect my patients and staff. 8 pm-giving report to the TWO night shift RNs (one taking 4-other taking one of mine-does something seem OFF here to you???) 9 pm Walking through the door to my most excellent husband-best friend I expect to be asked to come in for DT on my days off. Not only no, but H-NO!

We usually have 3:1 without a tech. Do our own blood draws, orders, and ECG monitoring. 5:1 with a tech. Sometimes the tech can do all the delegatable stuff, sometimes can do little more than VS and baths. The other day we were short staffed and I had 6 patients with a tech that was a newbie...no phlebotomy...no orders, and didn't know how to read tele. UGH! These were patients on higher acuity than norm also. Told me that I was given that particular assignment because I am a "strong nurse." I don't think it's safe, but what can you do when there is no other alternative, and I KNOW it? I have recently learned the charge role, and although there is a matrix that we "need" to follow, it gets tossed out if the hospital is threatened to go on divert. Sometimes, the charge has a pt assignment as well. There are no "laws" that protect us here (like the ratio law in CA). It gets very frustrating for the floor and the charge. The directors just go home at 5pm and leave the oncoming charge with the wrath that is certain to happen when the night shift gets their oversized assignments. One night, there were FIVE rns for FORTY patients! And ALL were tele! Needless to say, we have a high turnover rate of rns (the major reason that the previous admin was fired). Other floors in the hospital, there is a 4:1 WITH a prn tech, AND a secretary that does orders. And those are regular med-surg WITHOUT tele! Hmmm, now how can we prevent this high rn turnover????

The unit I work in is "Progressive Care," aka "step-down" or "telemetry." We have a 3:1 ratio if no tech, 1:5 with a tech. We do all of our own blood draws, orders, ECG monitoring (via stat view), and follow up phone calls. In short, it is a heavy workload floor. I would question this variability re: admissions and discharges. The MOST busy day is when I have a high turnover of patients. I would inquire (if I were you) about the turnover among NURSES on the unit. This can speak volumes about the work environment and expectations. But....I just noticed that you already took the position, so I guess this suggestion would be outdated. BUT you can always opt to go back to your previous unit if it doesn't work out for you (depending on your hosp policy). Good luck!

#3. First/only female. No ETOH