KlareRN

Hi! All states have their own "state regs" that you have to follow within your state- and EVERYONE has to follow the "federal regs" throughout the US. Some states have taken some of the federal regs and expanded them or given more specific requirements that you need to follow to be in compliance. Nursing practice is to follow whichever regulation is the strictest because if you don't adhere to the strictest reg; you will get cited during a survey. An annual survey (or complaint survey) can and will "tag" you for state OR federal tags...so you have to follow both. State tags are sometimes referred to as "it is only a state tag...I'll take it over a federal tag..." But it is still a tag that needs a plan of correction and a revisit for compliance. If you are the DON in a long term care facility- you should ask your administrator for a copy of the federal and the state regulations so you have them at your fingertips. You should also spend some time with the federal regs (we call it the "watermelon" book because of the color of the cover.) Although alot of it is interpetation- it at least will give you some insight on what you should or should not be doing. Good luck!

I am currently working as DON in a facility similiar to the one you are working in. We keep the same staff on our dementia/alzheimers unit to help reduce confusion for our residents. Out on the other 2 halls- the C.N.As rotate every two weeks (on payday). We provide C.N.A assignment sheets that are kept very detailed about resident care. Every aide is expected to have a current care sheet in their pocket at all times for the area they are working. By rotating; everyone gets the chance to "enjoy" those residents that are more demanding and who has family that are VERY involved!! This also prevents aides from not being able to come in when there are call-ins because they "have never worked on ____hall" and "I don't know the residents." I tell all applicants during the interviewing process that they will be expected to work all sections. If any of them try to pull any crap later- I just tell them that "hall ____" doesn't issue their paycheck- the facility does. All jokes aside- most of the aides want to rotate to prevent any of their co-workers from having to deal with difficult people very long. I am very fortunate that my aides really do care about each other for the most part. I do keep the same licensed staff on the same sections. I think that the residents in long term care can have a change in condition slowly and a nurse that has not worked with that resident may have a hard time pinpointing what the issue is. All facilities are different though. But- this rotation of the C.N.As works best for us. Good Luck

I have worked in management in long term care for several years and every facility I have worked in has the same policy: If a person is not a DNR- you are to initiate CPR and you send them out 9-1-1 no matter how you find them unless: -Obvious lividity is present or -they are decapitated (God help us in LTC if this is EVER the case!!!) These are the only 2 reasons policy has allowed a licensed individual to make the determination that coding someone is not necessary. Doesn't really give us much credit does it?!

At the facilities I consult in we use low beds, bed and chair alarms,baby monitors, and motion sensors. If you choose a baby monitor- make sure that you do not call it that. The state may cite you for a dignity issue. We careplan them as "Adult Sound Monitors". Also- we buy the motion sensors from a local Radio Shack. They work as well as any of the more expensive ones you will find in your supply cataloges. The motion sensor uses a light beam that alarms whenever the beam is interupted. Maintenance attaches one part of it to the wall at the head of the residents bed. Then we attach the other part to a portable base (maintenance made some similar to the standing "wet floor" signs used). When the resident goes to bed- staff position the "portable" piece of the alarm at the foot of the bed and turn it on. By having a portable base- it can be moved out of the way during the day (stood in the corner of the room) and that piece of the alarm doesn't get lost. Before we started using this base- pieces of the alarms kept disappearing (res picked up and carried out of the room, got knocked into the trash, etc.) The base will help to keep your expenses down. Also remember if you choose to use a beam alarm- put the bed against the wall so the resident has to get out of bed on the side the alarm is on. Residents who have parkinsons and other disease processes that make their gate/balance a challenge are difficult to care for. We have come up with ideas for safety while in bed but a bigger challenge is how to keep them free of injury while they are ambulating. Have you discussed an adult "merry- walker" with this resident? It is a piece of equipment that is made from PVC that serves as not only a balancing tool- but also has a seat for resting. They are available in therapy cataloges. Although it is an assistive device- this resident should be able to release it independantly. There are alot of mixed feelings about these walkers (dignity) but the safety of the resident needs to come first. Unfortunately discharging this resident to another facility will be difficult because when they come in to assess him and read the chart- they will see the concerns and there is no miracle out there that one facility has that will solve the problem of an independant resident that falls. And in order to discharge- you have to have somewhere to send him...or you can't discharge. Good luck- if we think of anything else-we will pass it on to you. klare

The state of Indiana has passed a new scope of practice for QMAs. Under the new guidelines; a QMA can administer G-Tube meds, do glucochecks for BS, and some more critical dressing changes. In the facilities I go to- we are leaving it up to the facility to determine if they want to widen the scope of practice in each individual building. And- I think the nurse supervising the QMA should also have the option to say yeah or nay. Do other states allow Qs to do more skilled practices like these? I am afraid that this will cause an increase in Qs on the floor because they are cheaper and easier to hire than a licensed nurse because they want to "be a nurse". I have worked with some very good competant Qs but I always have to remind myself that they are just a CNA that has had the medication class. I am certified to teach QMAs but am still leary about broadening what they can do. Would you allow a QMA working under your license to administer G-Tube meds and tell you what a residents blood sugar is so you can administer the insulin? KlareRN

ktwlpn- You are the kind of nurse most of us would like to clone to work on our dementia units. Too many are too quick to pop a pill than to take the time to be human. I agree that if a person doesn't want to be in bed at 10pm; let them be up. In fact- get them a snack and help them find something on the television or a magazine to look at. Better yet- put down the magazine you are looking at and have a conversation with them. No- they may not understand the meaning of the conversation and they may not remember it even took place; but for that short period of time you are validating their value as a person. Too many times these folks are people who may have worked 3rd shift- or never got up before 10am...then they become confused and we force what we think is right for them and tell them what to wear, what and when to eat, when to bathe. when to go to bed or when to get up, not wearing a nightgown to breakfast, etc.... It takes a special person to be able to work on secured units. I believe it is the most challenging area in any facility. The behaviors can escalate quickly and the repetiveness of the daily routine can be draining. Unfortunately it sounds like you work with a difficult bunch that may need to work in another area. Telling a confused resident that their mother is dead is not only cruel- but can be verbal abuse if it causes any anguish or mental distress to the resident (even for a minute). We are also careful about our choice of words for that same reason. Our babies wear bibs- our residents wear "clothing protectors"...our babies wear diapers- our residents wear "incontinent briefs" etc... Your local alzheimers association may be able to supply you with some teaching materials or at least point you in the right direction. Good luck to you- I hope you can continue to make a positive difference in the lives of the ones you care for... KlareRN

ACNORN- Thank you for telling it like it really is but be prepared...you are bound to get alot of flack for what you said. The truth is- staff nurses say "that is why you make the big bucks" not realizing that our hourly wage is usually about half of what they make because we do not get paid for anything over our salaried hours and in most facilities- nurse mgt does not get the "bonus" offered to floor staff to cover. Our "dose of reality" on the floor is done for free. Unfortunately most of these nurses that keep telling us to come up with an answer are the ones who can either screen the phone calls coming early Saturday from the facility or simply say "sorry- I just can't come in and help". Then they go on about their weekend off and do not give it another thought because "they are not scheduled to work". Also-SmilingBluEyes suggests paying a "good differential for those difficult shifts". What is a good differential? Isn't a $100.00 bonus a "good" differential when it is in addition to your overtime and shift diff that you are already getting? What do you all consider a "good" bonus to pick up a shift? Hiring staff to cover these shifts is impossible. At least in the northern half of Indiana- there are no nurses to hire period. We have one of our facilities that the DON is working at least 2 shifts every weekend as a staff nurse because there is NOBODY to work. Even the agencies are unable to staff alot of our buildings. The licensed staff is picking up as many shifts as they can but they are tired....and there is not much hope in thinking all the sudden it is going to rain nurses. Our company is offering a $5000.00 sign on bonus as well as tuition reimbursement and we pay very well...still no takers. It just doesn't look good.... KlareRN

I am not frightened to defend myself...what I am is frustrated. Some nurses just continue to justify their poor behavior. Remember I never said ALL call-ins were avoidable. What we are talking about here are nurses who have abused more lenient attendance policies leaving no choice. Those who are abusing the sick benefit are the ones who are making it so difficult for everyone else. They are usually the ones who start defending their "right" to call in. For all of you who are saying that a make up policy is unfair and that sick time is a benefit that you are entitled to without penalty: How do you propose a facility cover your shift when you call in? Remember- 1. We cannot "force" anyone to work over to cover 2. Agency/pool may not be able to cover on such short notice 3. Pulling from another unit will just make them short 4. Your nurse manager works Mon-Fri and happens to also be sick on this particular Saturday morning 5. We can call someone scheduled to work next Saturday and promise them the next weekend off if they will come in and cover- but we cannot require you to work next weekend when you are feeling better to cover their shift so they can cover yours today For all of you who tend to start slamming mgt for trying to control a bad situation....what is your answer???? Trust me- those of us in management are looking for it and if you can come up with it- you might enlighten all of us!!!

We also use the "if you call in sick on the weekend you are required to work the next weekend" policy. The catch is that the staff are informed upon hire that when they work the following weekend- it is on the shift where they are needed most- not necessarily the shift they usually work. There is no excuses accepted (i.e. "I don't have a second shift babysitter, etc....). This has helped with call ins. My company also has a rural facility with no pool to pull from. We have run ads and have gotten nothing and our licenced staff is now down to a bare minimum. The nurse management team rotates on a "short call" program where they try to cover any call ins for the weekend. If he/she finds nobody- unfortunately he/she has to work on the floor to cover the shift. It stinks-but somebody has to cover the shifts. The nurses have already said that if we go to mandatory overtime or require the Monday-Friday nurses pick up an occassional weekend- they will quit. The nurses in northern Indiana know that they can pretty much walk out today at 1:00pm and have a full time job by 2:00pm. Thank goodness we have some fantastic nurse managers that go above and beyond to care for our residents.

I agree with bandaidexpert. Most facilities in northern Indiana are having the nurses sign a "Master Signature Log". (Our pharmacy supplies our forms). A rubber stamp is used to stamp the back of each MAR/TAR sheet that says "See master signature log". Each med cart has a COPY of the signature log. The original is kept in Medical Records to ensure it does not accidentally get lost. This saves ALOT of time that the nurses don't have anyway! This is legal and accepted- the catch is that you have to make sure EVERY nurse is signed in on the original form.

I am in northern Indiana (about 125 miles north of Indy). I think the pay here is pretty good. In long term care- LPNs right out of school can start at $16.00-$18.00/hr. Shift diff is usually $1.00 for 2nd and $2.00/hr. for third. Working a weekend will get you an additional $3.00/hr plus shift diff and hourly rate. And...you can get "shift pick up bonuses" anywhere from $25.00-$100.00 per shift. RNs can pretty much write their own ticket in long term care up here. The federal regs require 8 hours of RN coverage 24/7. So- facilities are desperate for weekend RNs. It is not unusual for a weekend "supervisor" to work 8-12 hour shifts and get paid at least $25-$30/hr. In alot of facilities- the supervisor never works on a cart- just is available in case of a problem. Usually just walks around and does some PR. I have not exaggerated here- northern Indiana needs nurses. Alot of facilities are looking for DONs with starting pay no less than $60,000/year. If you are able to relocate- we could sure use the help!!!

The state surveyors are now asking for "proof" that agency staff have been oriented. They especially want to see that agency staff know things like where fire extinguishers are, crash carts, how to work the paging system in case of an emergency, how to use the phones (to get a line; what number to dial to get a line, etc.). They are also asking for proof that the agency staff is aware of the abuse/neglect policy/procedures. The agencies in my area are willing to pay their staff for an orientation-usually by having them come to their office and reading a folder designed to give them a quick overview. Then- hopefully they are given a tour their first time in the facility. I do not think the orientation is supposed to be designed to "teach you how to do your job" as some assume it is. I never worked agency- but if anyone knows how to do the job- it is them! They are expected to fall into place and are held accountable just like the "regular" employees. They have to be flexible and understanding- (you know they get the heaviest halls with the poorest staffing in a lot of places). I think the reason for the orientation is to ensure that the agency staff are prepared to assist in an emergent situation.

I have obviously hit a nerve that I did not intend to hit. From my side of the desk- yes- I have my job to do. I guess what makes my job different is that in the position I am in; if we are "short" due to call ins, nobody picking up, etc.; it is my responsibility to cover the floor. Yes- I do work the floor on an almost regular basis. WHY? Because I will not require you to stay because the next shift chose not to come to work. I see how hard you work (office is next to nurses station- door open-constant stream of nurses coming in to complain about each other) I will ask you to stay- but you have committments after work. I have seen you (and heard you) working "short" today because 2 of your CNAs called in (no car and fight with boyfriend) and I know you have not taken a break. I have apologized and spent 2 hours on the phone trying to get staff to come in. (thanks to caller-ID; mostly answering machines).So yes- I stay because someone has to provide the care for the pt. But- I will hear a constant line of "well you should have gotten someone to come in."Oh-by the way; I am on salary so I am staying over and doing this for "free". There is no overtime, half-time, anything. Your response will be "because you make the big bucks." NOT!! I may make more on paper- but taking the actual number of hours I work divided by my hourly rate- I make less than any of my floor staff. I have gone over the line and offered as much as a $150.00 "pick up bonus" to get a shift covered and been told "no- but that plus a gift certificate and a day off with pay and I'll do 1/2 a shift for you." I know people get sick and need to call in. I have children and they do get sick. The legitimate call ins are not what I am referring to. But- how odd that where I work- if it looks like we will be down a nurse; guaranteed another nurse will be calling in (usually the same one every time) or when someone is floated to another area- they are suddenly sick and need to go home. The best is when they "just got a call about a sick child"- but I have been covering the desk for the last 45 minutes and no calls were recieved. (I have ALWAYS let nurses go for sick children..ALWAYS) I have alot of nurses that reply the same way Heather did saying "that is YOUR job." Well- your job is also my job. When nurses choose to not show up for work and only give an hours notice-I know I will be staying. It doesn't matter that my son has a game or that I was going to write next months schedule to get it posted tonight-I will be on the floor. And most of you know that unless there is an emergency in the building or an act of God outside (tornado, etc..) I cannot mandate that you stay. (Abandonment is a joke- although alot of people threaten to "take your license for abandonment"...never will hold up in a court of law unless that walking nurse was the ONLY nurse in the building). Oh- and since I am staying to be a floor nurse- would you mind taking the schedule home and getting it ready to be posted...it is already 2 days late and nurses are complaining they do not know when they are working next month. And by the way- I need to investigate our supply charge outs to figure out why our supplies are over budget for the month- would you get that ready for my AM meeting with my boss for me? I will be here on the floor if you have any questions- call me from home. Oh...and would you come up with something for nurses day? Lets just agree to disagree.... Klare And Jules- I would never think of floor staff as being the "lowly"ones. And- yes your job is actually more important than mine. You care for the pt. What could be more important than that? I work in smaller facilities and have hands on time with pts and families. I call them to tell them their mother or father is dying, I sit and hold their hand because they have no family and the nurse is busy caring for someone else that is dying. I also comfort the new grad who just had her first code- I terminate the nurse who has gone beyond an acceptable number of call-ins ( no matter that she is a single parent and has a handicapped child that is frequently ill). I will cry afterword. It hurts because she had legitimate reasons. But- policy is policy and I cannot fight those above me because if I let her stay; then another nurse will come along and say why is her handicapped child more important than their child who had a cold? Why didnt she get terminated? Unfortunately- until you have been on my side of the desk- it is difficult to understand the bottom line, etc. I too wish I could forget about administration and pay the nurses what they really deserve and improve the working conditions by adding alot more staff. But it will not happen. I am sorry that most of you are not told by your management that you are appreciated other than for Nurses Day. I am also sorry if you have consultants that have been in management so long that they have forgotten what it is like to be in the trenches actually doing the work. Please believe me- I am not that consultant! I play in both back yards...yours as a nurse and administrations as a consultant.

Interesting thread but I am torn...been on both sides. But- I am shocked at the response of the nurses who receive the "junk" stuff you all are mentioning. What do you expect? In most companies- the budget for employee benefits is limited. (Usually those that write the budget don't think it is important enough to warrant alot of money). It is used not only for nurses week- but for every other departments other "day/week/etc.." There actually is housekeepers day, laundry workers day, etc. The person who is responsible to purchase items is limited to their budget. Unfortunately- if you are in a small facility (with only 25 nurses) even spending $15.00 on each one is $375.00. Although the larger hospitals have bigger budgets- there are is also more staff. Consider the prns, the part timers, all 3 shifts. And- for $15.00; what would you get? Not much. Of course we can blame "administration" because "they" dont appreciate us; but like I said; they have budgets that limit them. Do you expect your nurse manager to pay for things out of their own pockets? (Been there-done that. Not going to do it again-they complained about the gift) Should managementoverceed the budget so the nurses are more appreciative (for a day) and take a chance on losing their job? (Not staying "in budget" is reason for termination in alot of companies) We all know that even if we got elaborate gifts; we would ridicule it and say "they should have...." I am not "selling out" on my peers- but due to a change in the administration of a facility I consult in; I have to come up with the gifts for nurses day. Due to medicare/medicaid cuts; there is a very limited budget and I have to buy for 13 nurses. Even an empty mug is $6.00 each. I am sure whatever I come up with will not be valued by the floor staff. They will smile when they get it; then go to the nurses station and complain/ridicule it and say that "they should have given us a raise instead" (be realistic!) Of course they want more staff, better pay, to "be appreciated every day" yadda...yadda... What do I as an RN want for Nurses Day? 1. For the floor staff to quit whining about being "short staffed". If their peers would quit calling in and come to work; they would not be "short staffed" Some of the energy used to complain about it should be used to help come up with ideas to recruit staff 2. To not be told for one whole week that they are overworked. We are all overworked and there is not a very bright light at the end of the tunnel (welcome to healthcare) 3. Do not assume that because I sometimes am in an office behind a desk that I do not have alot of work to do. Not only will I be in the building for at least 10 hours- but I will take work home and get phone calls into the night to solve "nursing" problems when the licensed staff cannot supervise the building. (I am not complaining- I chose to take a management position) I spend the greater part of my time trying to figure out how someone made such a huge medication error, recruiting staff (that you will drive out of the facility by your rudeness), defending the care you are providing to irrate family members, pacifying the medical director, counseling the previous shifts nurse that you have done nothing but complain about because of what she didnt do before you got here, shuffling the schedule to make sure there is at least some staff in the building, writing evaluations (so you might get a raise), checking admission/discharge paperwork (that is never complete), scheduling inservices (that you will not come to), and designing some kind of gift for nurses week (that you will not like)..yadda...yadda 4. Most of all- I would love to just have the nurses appreciate that there is a week set aside to recognize them. I would be thrilled if one of the nurses in one of my facilities came up to me and handed me a cheap keychain and said "Happy Nurses Week." If you came into this profession looking for recognition and praise- you are sadly mistaken. Nurses are overlooked, overworked, and overtired. I realized this during my first clinical experience in school. But- I didnt choose to become a nurse to get a pat on the back or expensive gifts or to become rich. I became a nurse to give compassionate care to my patients. Everyday is nurses day because everyday at least one patient smiles at me...that is gift enough. When you get your cheap piece of "junk"- appreciate the fact that you had what it took to get through school and have what it takes to stay in the profession. No gift has enough value to compete with that. Happy Nurses Week- Klare

My mom also told me the bubblegum story. I once was making cookies and ate a large portion of the raw cookie dough. My mom told me that the ingredients in the dough that cause it to rise (baking soda and powder?) would make my stomach explode if I really ate as much dough as I thought I did. I layed awake all night thinking my stomach was really going to explode!!!