kaliRN

Agree with all above and enjoy the dialogue on here and multiple responses especially Ktiger spot on information- ceiling lifts are often the ideal solution for space, ease of use, limited disruption of the environment and events (besides applying the sling which becomes second nature - it’s not so disparate from carrying your own child when that’s no longer a safe and feasible option) I know you’re reluctant on the sit to stand but based on your child’s baseline mobility - if he uses or could benefit from the use of a gait trainer - I have seen great benefit in the Rifton TRAM https://www.rifton.com/products/lift-and-transfer-devices/rifton-tram You would need to trial it when he is weight bearing and decide if it makes sense for your home environment (yes you still need pathways but I find it significantly more maneuverable than most hydraulic lifts), the real advantage if it suits his abilities is it allows the child to participate in the transfer process and as I’ve been told is much less “scary” than being suspended in a traditional lift Thank you for the reminder of needing compassionate and thoughtful dialogue, this is something I consider a critical component of managing long term care needs for our patients and one of the examples of how delicate and “real” the emotional and practical aspects of this necessary intrusion are

Can any of those who posted about using electronic charting share what systems they are on? We are looking at potentially converting but have thus far only found charting modeled for intermittent visits.

Agree that there’s certainly challenges with using a school nurse - just giving the OP another perspective as I would if she was one of my patient’s parents to consider. This might be a transportation policy where you are - the parent would have to find out if this is the case where she is. I have many cases where the night nurse stays and gets the child ready for school or the and sees them to the bus and the afternoon nurse accepts the patient from the school nurse or the parent is available at one of those times. Of course as in all situations, it could be very stressful for a parent to be reliant on the availability of back-up care, that’s the primary reason I’m suggesting the school nurse. The 1:1 aide and LVN doesnt apply to this child per the OP’s statement. The OP’s child doesn’t fit what I had in mind, I was considering a child who needed very scheduled specific tasks - such as GT feedings or administration of routine and low-risk medications vis GT or scheduled catheterization times but only safety monitoring during class times.

I would ask your agency the question on hours, for us, there are certainly ebbs and flows to nurse availability, with the most difficult to staff almost always being weekend and NOC hours (which it sounds like you’ve already struggled with). If you are flexible, I would give your agency the opportunity to find any available shifts based on nurses hiring on. Just let the agency know you are trying to find reliable care but have some flexibility in how you use the shifts, so the next time a nurse comes in looking for full time work regardless of the hours they’re available - you’d like to meet them? Can you work opposite your husband for a time until you feel comfortable with a nurse being reliable and available?

The entire response was Hppy was very insightful, I did want to add the review of your personnel record is also subject to state mandates. In our state, the employee may request to review AND receive a copy of their personnel record in its entirety as it relates to their performance or any grievances filed against the employee. The employer may only charge the actual cost of duplication and postage if requested to mail the copy, all the employee need do is submit a written request As far as next job opportunities, someone mentioned maybe reaching out to a charge nurse or someone else in a supervisory position that may be willing to help with a reference that could be contacted directly. I would agree with Hppy though - if HR will only provide employment verifications and not references for liability reasons they will be highly unlikely to disclose anything at all about the reasons or even nature of your separation (whether it was voluntary resignation or termination) - many will give only title and dates of employment and not even answer “is this employee eligible for rehire?”

As all have stated, you need to look out for yourself and be able to guarantee your patient’s safety so you don’t end up making a costly error where your license or your patient’s life is at risk. Whatever your State mandate is on consecutive hours is a good starting point, but even if they don’t have one, you can simply state your own limitations should this situation arise: “I am sorry you have to find another staff member, but I need to leave after xxx number of hours otherwise I don’t feel I can safely manage my patient. I want to help as much as I can, but I know our patient’s safety is the top priority and that’s all I can offer” ... thing is if you continue on this case and they have not found a replacement you would need to call 911 to report off or be at risk for patient abandonment ... it would be messy but not as much so as you falling asleep and your patient being injured or dying

This is spot on - child or adult - willing and available caregiver should be a requirement for any agency in my opinion (here it’s state mandated but I would absolutely make it a requirement to be on service even if it weren’t)

I find this statement so sad “the agencies encourage this behavior because the nurses are expendable” - my nurses are the reason our agency stays in business. They are the very backbone of what we do and while there’s so many challenges in shift care as it relates to nurse-family dynamics ... never would I consider a nurse expendable. Yes, I have limited ability to mandate how a family behaves (unless it’s outright abusive or unsafe), but I always try to mediate and create a better work environment whenever I diplomatically can. If I can’t - I will certainly restaff a good nurse should they be truly unhappy or unable to “get along” with a patient or their family

It does not sound worth it to your mental or emotional health, if this was reported to me by a nurse I would work to re-staff them with anything I had available and then explain to the family exactly why I was forced to remove them. I would definitely say the quick turnover on this case and the parent’s choice to employ outside an agency are huge red flags and clearly have to do with the mother’s unacceptable behavior and attitude. All the best to finding something better

Is it your choice to have a PDN nurse attend school with your child because the school is using trained medical 1:1 aides and you are uncomfortable with this? Have you explored requesting/ requiring the school to employ an LVN to accommodate your son’s medical needs while on campus as part of his IEP? Since it can be difficult to find a nurse, guarantee their ongoing devotion to an assignment, and replace a nurse should it becomes necessary... often parents leaving the school district to be responsible for providing a free and accessible education by meeting the child’s medical and academic needs (with a 1:1 aide, 1:1 nurse, 1:1 aide and specific times the LVN attends to the child in an appropriate and dignified manner) is the best solution to guarantee the child’s unencumbered attendance. Not that it should matter but from a particular standpoint- State funding is student census based here, so home/hospital is usually a much more costly solution for the district and accordingly they may be motivated to properly staff a child at school so they can attend. If you have good input from the child’s physicians and a detailed overview of accommodations during the formation of the IEP - it’s certainly worth exploring if you can have the school accommodate with their own staff and then should a PDN nurse become available through your agency maintain the right to send the PDN nurse with your child instead.

Just wanted to provide a last bit of encouragement, do not feel like you have to disclose your injury to refuse this case. Simply state the truth, that there is no lift in the home and the child is non-weight bearing and significantly over a safe transfer weight and the parents will be either unavailable or unwilling to assist with safe lifting and transfers ... since this creates a patient safety issue you don’t feel comfortable working in that home environment. Good luck! I hope they find you a wonderful and safe next assignment

Well I hate to read that, having a trained nurse employed to provide skilled nursing services for a child who qualifies for them is the exact reason these programs are in place, a parent is certainly the best equipped individual to do this especially once they’ve obtained licensure. It is so wonderful to create a home environment where a parent who makes the choice to stay home and meet their child’s medical needs can support themselves financially doing so. I hope this will change in your State (and if I knew your State well enough would share how to advocate as such) On to your more immediate statements, I can say if you were without nursing in my agency, it would be because I just couldn’t get someone in the door whose hours matched your desired shifts (or anyone in the door at all). I know my “challenging” families (but abusive or unsafe work environments would not continue if they were reported to me either) - when I have a “desirable” home, family, and patient ... I just have to get someone in the door - so if you are successful in meeting a nurse from an advertisement - I would keep contact and if you felt they were removed to meet agency’s needs you might know where you stand. Nurses and families do communicate and many of the stories of agencies doing unethical things (moving nurses to another case against their wishes to a higher priority case for example) were reported by the nurse to the parent directly in confidence. I hope you find your “match” soon

Not sure where you are located, but here in California, recruitment is the most difficult part of the job. LVNs are required to have a year of experience before working for an agency and reimbursement rates were just increased for the first time in 19 years so wages were dismal in comparison to other job opportunities. Great advice from caliotter to advertise on an employment website such as Craigslist or some families choose Care.com (though this is much harder to find LVNs on). Agree from what you describe here that you have a lot of the “preferable” work assignment qualities. The challenge may simply be finding a nurse who is willing to travel to your location and/or work the hours you are working for Certainly not every agency is reputable and some do “business” by robbing from Paul to pay Peter (moving a nurse to a higher priority case), ours does not, but I’ve heard otherwise from patients and nurses I am curious- are you employed by your agency and working any unstaffed hours?

Parents may be resistant to putting a Hoyer lift in their home and counting on agencies to place “stronger” nurses or “only male” nurses (males and females all only have one back) Our agency follows OSHA guidelines and sets a 50lb weight limit, anything above that requires a two-person lift or a Hoyer. Period. I will assist a family to obtain a Hoyer, I will explain the importance of nurse and patient safety, I will respect a parent’s wishes if they prefer to do all transfers themselves with the assistance of my nurses or alone and delay a Hoyer (and continue to educate and encourage that they to could be injured), but I will remove my nurses from a home if this policy isn’t followed A back injury at work could cost a nurse their career, a patient injury at work has untold costs ... your agency needs to back you up on this and I would definitely decline this patient assignment.

@Ruby Vee Thank you for being courageous enough to share your story so transparently, I felt the mental and emotional turmoil so powerfully. Brought me to tears - so grateful your resilience is serving you on this new path. I remember being in the hospital, twice I had allowed the father of the child to attend with me at the appointments, we had separated after a second incident of violence this one during my second pregnancy in front of my child. Someone on an online community made me realize with their own raw story and honest recounting just how deep I was in the abuse cycle and what I would be facing if I left without the protection of a TRO to address custody. I was still so “in love” and wanting to keep our family unified in some way that I would never have thought to do this and yet I have no doubt that was a precious gift that changed the course of my life. Thank you for sharing your story, that person will never know but she may have saved my life, and she certainly protected me and my children from devolving into his power to manipulate and control us. You may have done the same with your story of resilience, strength, and courage. Your story struck me to respond because in the hospital twice during admission I was asked if there was any history of abuse or violence ... I allowed him to be present for these appointments so how could I answer honestly? I was safe, I was separated, I was legally protected and stable in my home environment, but if I needed any support, I could not have sought it then and I will always wonder if any one could be helped by more open ended questions in private. In my new life, I was asked these same types of question in front of my husband, thankfully I am truly safe now but still disheartening that not much has changed - across 13 years and 3 hospitals and a multitude of doctor’s appointments no one has ever truly “asked” me if I was or felt safe at home in a manner I could answer if I chose.

Since your case was "sealed" there is different access based on the company performing the background check. Be thoughtful when filling out applications about your disclosures. Read carefully the applications to nursing school and look now at the requirements by the licensing board in your state. States often require information pertinent to arrests, not just convictions, or convictions regardless of the final disposition. Meaning even if a record was "expunged" or "sealed" you are still required to disclose it. Not every company is going to have the same access, but to be sure, the resources that the state board of licensing and any federal job for which you apply have are vast reaching. Disclosing on future job applications is also a matter of state law. I am not giving you legal advice here, just advice about character - honesty - and considering the ethics of decisions you make. Many schools take into consideration the time since conviction, the nature of the conviction, and the actions you have taken to rectify your wrongdoing, as well as whether or not the situation would likely occur again. Same with the BON. Before you choose what not to disclose, think about those things. It might be much easier to look past a 7 year old indiscretion, but nearly impossible to look past a current choice to be dishonest. I know how this feels and how heavy a weight it is on your heart, so just be sure to think about the fact that people (even those at nursing school and those at the BON) are not so myopic. My nursing school background check came back "clear" because of the company they used (and my record weren't even expunged). The BON I disclosed and followed all the policies and requirements and had no issues. Don't let your past determine your future.

Check the stickies on this board. Also - have you asked your agency? Generally they have a wealth of resources. At ours, we have the patient sign a copy of handouts/education materials left in home. It helps document that teaching is being done and reviewed with patient involvement. It's a great help to me when I do recerts to see this documentation in the patient's home - gives me a better view on what the SN has been focusing on with the patient (so I can help formulate what remains to be taught or identify issues what issues have to do with noncompliance or medications v simple knowledge deficit).

I got "lucky" and came into the position of clinical supervisor at my private duty agency. I was working a private duty case - the opening occurred - and my administrator thought I would be a good fit. It's going very well. Provided more experience and challenges then only one patient. I then got a second job doing home health visits per diem. I still want to transition into acute care - now that I've gained more experience. I would think working in intermittent visits (if you have enough experience d/t Title 22 regulations and agency policy) - might be a more accessible area to expand your skill set and provide new challenges. Good luck! I feel like private duty is something for some and not others. It has so many advantages in the closeness to the patient and family - the low stress environment (hopefully) - and the impact one has on each patient's quality of life. However, for some it becomes mundane, seems a poor use of skills, and nurses feel a longing for "more."

It is refreshing to hear that so many nurses are working with ratios that they feel comfortable with to provide safe care. As I read through so may threads on here - it seems that nurses are being overtaxed at the patient expense for the hospital's gain. I am sorry to hear that LTC is still being staffed that way. I know an RN who worked before there was a 30:1/60:1 NOC ratio and in a 100+ bed unit he was the only RN on staff. He stayed a week. The current ratio under those comparisons seems monumental. But I also appreciate that the acuity of patients in LTC is ever increasing. Especially as it relates to skilled nursing needs and the RN/LVN relationship. I simply cannot imagine what 8 patients are like to one nurse.

So I recently learned on allnurses that California is the only state that has mandated nurse-patient ratios. I was honestly shocked and found it educational how hard fought a battle that was and how many other states are trying to pass similar laws. But it sparked my curiosity as to the average nurse-patient ratios in other states? What are the ranges of patients an RN sees on the unit/floor? In California the ratios are as follows: ICU, CCU, NICU/PICU, PACU, L&D, and ER patients requiring "intensive care:" 2:1 Step-down units: 3:1 Telemetry, Pediatrics, ER, Antepartum/Postpartum: 4:1 Med-Surg: 5:1 Psych: 6:1 *The only exception is a local or state declared emergency. I became an RN after this law was in place for some time, so I really would be interested in the experience of others.

Congratulations on this new opportunity! I hope you enjoy it and it fits you. So wonderful you had a shadow day ... I think that makes all the difference in taking the first steps into a very different aspect of nursing.

Home Health agencies who are Medicare/Medicaid certified are regulated by the Centers for Medicare/Medicaid Services. Here is an excerpt regarding verbal orders from the Medicare Benefit Policy Manual, as well as a link to the full .pdf document. Note that federal, state, and agency guidelines are all used to regulate the implementation of verbal orders. Verbal Orders — Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 30.2.5) "30.2.5 - Use of Oral (Verbal) Orders (Rev. 1, 10-01-03) A3-3117.2.E, HHA-204-2.E When services are furnished based on a physician's oral order, the orders may be accepted and put in writing by personnel authorized to do so by applicable State and Federal laws and regulations as well as by the HHA's internal policies. The orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services. The orders may be signed by the supervising registered nurse or qualified therapist after the services have been rendered, as long as HHA personnel who receive the oral orders notify that nurse or therapist before the service is rendered. Thus, the rendering of a service that is based on an oral order would not be delayed pending signature of the supervising nurse or therapist. Oral orders must be countersigned and dated by the physician before the HHA bills for the care in the same way as the plan of care. Services which are provided from the beginning of the 60-day episode certification period based on a request for anticipated payment and before the physician signs the plan of care are considered to be provided under a plan of care established and approved by the physician where there is an oral order for the care prior to rendering the services which is documented in the medical record and where the services are included in a signed plan of care. EXAMPLE 1: The HHA acquires an oral order for I.V. medication administration for a patient to be performed on August 1. The HHA provides the I.V. medication administration August 1 and evaluates the patient's need for continued care. The physician signs the plan of care for the I.V. medication administration on August 15. The visit is covered since it is considered provided under a plan of care established and approved by the physician, and the HHA had acquired an oral order prior to the delivery of services. Services that are provided in the subsequent 60-day episode certification period are considered provided under the plan of care of the subsequent 60-day episode where there is an oral order before the services provided in the subsequent period are furnished and the order is reflected in the medical record. However, services that are provided after the expiration of a plan of care, but before the acquisition of an oral order or a signed plan of care are not considered provided under a plan of care. EXAMPLE 2: The patient is under a plan of care in which the physician orders I.V. medication administration every two weeks. The last day covered by the initial plan of care is July 31. The patient's next I.V. medication administration is scheduled for August 5 and the physician signs the plan of care for the new period on August 1. The I.V. medication administration on August 5 was provided under a plan of care established and approved by the physician. The episode begins on the 61 day regardless of the date of the first covered visit. EXAMPLE 3: The patient is under a plan of care in which the physician orders I.V. medication administration every two weeks. The last day covered by the plan of care is July 31. The patient's next I.V. medication administration is scheduled for August 5 and the physician does not sign the plan of care until August 6. The HHA acquires an oral order for the I.V. medication administration before the August 5 visit, and therefore the visit is considered to be provided under a plan of care established and approved by the physician. The episode begins on the 61 day regardless of the date of the first covered visit. Any increase in the frequency of services or addition of new services during a certification period must be authorized by a physician by way of a written or oral order prior to the provision of the increased or additional services." In our agency, all verbal orders, including those for therapy services are signed by an RN case manager (including those received by an LPN/LVN) before being submitted to the physician.

I just wanted to state that I find this thread even at old as it is a tremendous source of misinformation. While I believe any person moving to a new location should visit before moving and creating a life and career there, Guam is a US Territory and there are no tremendous infrastructure issues. Google searching for articles written by people who have never set foot on the island is no more accurate then other people who have posted here and never seen the island. Saipan is a lovely place, but it is NOT one and the same with Guam. Let me give you the truth in what has been stated here. Guam, much like the Philippines, does experience typhoons and some have been extremely devastating to the island. Causing massive property damage and loss of electricity and even water for some time after the devastation. It's tragic, but keep in mind these are storms much larger than Hurricane Katrina and there is no loss of life. In 1993, an earthquake estimated at 8.0 occurred, not a single life was lost, and only one building (an uninhabited hotel) had enough structural damage to have to be red tagged and subsequently destroyed. Think of the tragic earthquakes on the mainland and overseas in the 6.5-7.0 range. This is for two primary reasons. The first is location, Guam is above the Marianas Trench, the deepest area of the Pacific Ocean, so there was some difference in the manner in which the tremors occurred. Second because of our constant typhoons, almost all homes are built with deep foundations and made of concrete. Unlike some of the Gulf Coast, where rebuilding must occur post hurricane, these home withstand large amounts of weather. It is possible that the poster spoke to nurses in the aftermath of a particularly devastating typhoon (this is not an annual occurrence - never once was my home or any of my family members flooded). I am posting because I honestly felt disrespected. I was born in California, lived on Guam for approximately 10 years, it is home in my heart. If you want to discuss some of the issues at GMH, I would be happy to PM anyone who searches and find this post, it is far from the ideal hospital. However, I do not want this post to go unanswered when there are so few on this site about Guam. I have been to underdeveloped countries, Guam is not underdeveloped. Is may not be up to par with certain standards, but the military members I have spoken to often remember this fondly, people - things - are simpler - slower. If you ever been outside of Waikiki in the areas of Hawaii where just the locals are - you may know what I mean. But that's why you should visit - everyone speaks English - so it would be an easy visit to make. I hope this helps anyone reading this post even though I am sure the OP long ago made a decision. So much information is dispelled about Guam, about snakes running rampant (not true - not even close - I assure you many of who lived there their whole lives have never even seen one). Guam is sort of mysterious to some, this tiny little island out there in the South Pacific, a U.S. Territory. It's like many things that people never get to experience, it's rumored about, but poorly understood. Thank you for reading my vent

There are several local hospitals that are allowing patients to make reservation to the Emergency Room. I don't work in the ER - but I just don't "get" how this is an acceptable practice. Would you be on board? http://miami.cbslocal.com/2011/05/22/hospitals-offering-reservations-for-er-visits/ http://www.fiercehealthcare.com/story/hospitals-take-online-reservations-er-appointments/2011-01-31

I would approach it just that way, "Dr. Such and Such, I had a patient with the following symptoms: * & ^ that are very similar to this patient. It turned out to be disorder X. Because it present so rarely, we only found out after running Y diagnostic. Would you like us to try that here?"