blessedmomma247

I started working at a small LTC about 6 mos ago after moving across country for my husband's job. I work night shifts, some 12 hr shifts but mostly 8 hrs. This facility is the smallest I have ever worked at before. With a full census we are at 55 beds, with 35 beds for long term care and 20 beds for the TCU. I am the only nurse during the night with two cna's. There is also the assisted living apartments in the back. During the night, I am considered to be on call for them and go there if there is an emergency. Which if I am needed, then I am sending some out to the ER. There is about 150 apartments with 220 residents. I have only had to go there 3 times. I do have an on call RN that is able to help if I need it. For the most part, my night shifts are okay...the occasional falls, residents on hospice ect. Mostly, I give a lot of PRN's for pain and do a lot of pain management with the TCU residents. I tend to do a lot of what the PM nurse couldn't finish. Making sure we have what we need from pharmacy. Last week we had state come in and they did not find anything...zip..zero..zilch. I barely knew they were here except the signs posted on the door and at the nurses' station. I happened to be working a 12hr shift the 2nd day they were here and I knew they were in the building but that was it. Not quite sure how we got no tags or anything. There is no such thing as a perfect place. We have our share of problems!! But all in all, I am very happy here . The DON is amazing and she will be in here in a moment's notice if I call her. She is very hands on and I have seen her help with a resident. I have only had a problem with one of the unit managers who likes to do things her own way and not be questioned about it. So I have learned to just say ok and that is that. I keep thinking things are too good to be true and I am waiting for the other shoe to drop. Any one else have a perfect survey?

Its the norm.. The key is having a good solid routine and stick to it. Create a cheat sheet to help remind you. Do you have a laptop on your cart? I use mine to set reminders to help. It takes a while to get a good routine set....and you will change it a lot before you get it right. Good luck!!

Def speak with the DON and ADMIN and if you feel like you got no where, report to the state. As a NOC nurse, I do not have labs in the middle of the night....and I do my best to limit vitals in the middle of the night; esp if they are stable. I do start my med pass at 4am, but a resident can prefer to take meds when they take their meds at home.

I have been an LTC nurse since 2009 and before that I was an CNA for 8 years. I will say it takes a special person to work in LTC. As mentioned above, you will have a lot to deal with. I have worked other shifts in the past but I prefer the night shift and have worked it for years. Not everyone can do nights. It takes a toll on your body. You need a good support system...your family needs to understand to sleep during the day. You need to be strong and be able to work independently. In most cases, you are the only nurse with two aides. At my current job, when we are full, I will have 55 residents, with 20 of those on the rehab/sub-acute unit and 35 on the long term stay unit. To make my life easier I have came up with the following (this can be used on all 3 shifts): ** You must have a solid routine. I created a time line and I stick to it. ( for example...I do all my vital signs at 1 am. I complete my charting by 2am and prep my meds by 3am and start my med pass at 4 am....) I think its perfectly ok to become a tad OCD with this. I have created my own cheat sheet and its my lifesaver. **Expect the unexpected and go with it. I have a resident who think he and his wife own the building we are in. He will come out during the night and want to know whats going on and demand to see what I am working on. I have a clip board of random papers for him. I have another resident who sees birds all the time and I have chased them out of her room many times. Same thing with spiders. ** When in doubt, send them out. Make sure you are following the patient's current POLST form and family wishes. DNR does not mean do not treat. **You will be short staff. You will have call ins. Know you policy and procedures on call ins. And remember..chocolate goes a long way. Ask your trainer questions. There is no such thing as dumb questions. Ask your supervisor for more training if you feel you need it. Feel free to ask me any questions!! Good Luck!

The house manager is supposed to making the appointments and arrangements for transportation. But there is one client who makes her own appts. The clients I am currently working with are wheelchair bound d/t paralysis (2) and one from a back injury. Most of them are able to make their own decisions and I have 3 that have dementia related illness. I have one young gentleman who has Prader Willi Syndrome and he is also wheelchair bound. All but one do have part time jobs. I did have the one patient seen by his primary re: his emesis.

HI guys, I am not sure if this is the right place or not to post here... I could not find a thread r/t group home nursing. I recently accepted with a company that manages group homes. I will be the LPN for two homes, 8-10 clients total. Ages and diagnosis vary. This is a part time job and most of it is working from home with bi-weekly visits to the homes. I am continuing my full time job as a NOC nurse in a LTC. I have been doing this for about a month and so far I like it and I am feeling very challenged. This job is way way out of my comfort zone. I like working with a team, with other nurses. Yes, I have my RN that I can call for support and questions. But for the most part, I am on my own. I find it difficult to leave my LTC nursing at the door..those rules and regulations do not apply in the group home setting. The staff that cares for the residents are not licensed by the state I work in . Yes, they have training and have taken a course, but they are not CNA's or NA/Rs or even med techs. I have one home that is having a major staffing problem. They have poor attitudes, hate their jobs, and are very rude!! I had one client that has stress issues and will make himself vomit. On my first visit, I found him in his room, under confinement because he had an emesis after supper the night before. The house manager had told me its their policy to isolate a sick resident for 24hrs and put them on a clear liquid diet. After further research, I determined the emesis was not r/t to a GI illness but to a behavior. So I made some changes to prevent that from happening again. I am working with the other nurses (its just 3 of us) and the clinical director to make some other changes as well. Like at least have TMA to pass the meds to help reduce med errors. Staff training and education to help reduce triggering behaviors. I would love some other feedback !! TIA

Hi guys...I could really use some help. I have a co worker that made a horrible mistake and I want to help her. I have worked with her on and off for several years. She has two disabled children, plus 3 other children. To make things worse, her husband was recently killed in a car accident back in October. Despite all this, she has remained a strong, hard working nurse. She loves her job and her patients. She is a great nurse. If there was a call in or extra hours that needed to be picked up; you can bet she was there. Then there was an incident where a patient who was in for s/p total knee replacement. The patient did not tolerant the surgery very well and had complications while trying to wake up post op. He was really confused and in a lot of pain. He also was allergic to a lot of meds...he even had problems with Tylenol (caused his nose to bleed). Anyway, one night, he was in a lot of pain, she gave him the PRNs he did have available and he was still in pain. She called the on call and while she was on the phone with the doctor, the patient fell out of bed and broke his hip. To make things worse; while in surgery to repair the hip; he coded and didn't make it off the table. There is this huge investigation and the family is suing. Two days later, when I show up to work, there is police and human resources. Everyone was getting pulled in and was questioned about a missing wallet from another employee. The IT guys were working on the video cameras to see and then everyone was shocked when they finally saw who took the wallet. It was her. And she admitted it when questioned by the police. She told them she only took the cash..$73...and hid the wallet in a resident's room. The police and the victim were able to confirm that no credit cards or bank info were stolen. She said she just panicked because she didn't have anything to get the kids for Christmas and was too embarrassed to asked for help. Everyone is so shocked by the news and would have helped her if she just asked. Now she has no job and is facing misdemeanor charges as well as the facing the board of nursing. The victim didn't want to press charges but the police are still investigating and the DON didn't want to fire her but it was out of her hands. SO my question is can she get another job ? What should she tell her future employer during an interview? What actions will the board of nursing take? A few other nurse and I took up a collection and made meals for her. SHe is completely sick over what she did. Even the victim is helping her and they remain friends. Thanks for your help!!

I agree with the comments above. I think it would be a good idea to sit down with them and dicuss your findings. I do not understand calling 911 for every single fall. Does the patient have the right to refuse to go to the ER? I have been an LPN for years and I have learned to work with my EMS crew. Calling 911 for every single fall is crazy. Do you have a non emergency transport in your area? We have Medics or AMR and if a patient is stable and needs to be seen, I either have a staff memeber take them or I call a non emergency transport. If the patients are falling that much..there is reason and they need to be more supervised (time to move them to LTC). If you are going to every single "FALL CALL" then it may appear that neglect or abuse is going on when there really isnt.

Thank you so much for the tips!!

Hi everyone...been a nurse for almost five yes and was a CNA for 11 yes before that. All of my medical career, I have been in LTC. Just started as a detox nurse and looking forward to this new adventure. Any advice/ tips would be great.

After 14 years in this field, I have made a decision. I recently accepted a position as a detox nurse at new medical detox center. This was a hard decision to make because despite all the BS I have endeared , I loved loved my job as an LPN floor nurse. This new job also requires me to move but it also allows me to be home the most when my children need me and to care for my special need daughter. And I might be able to finish school. In the last few weeks, I have been learning a lot about my new job and look forward to all the possibilities that lay a head. I wish every one the best of luck and will be checking in at times!!

Just wanted to update. I was called on Friday by staffing to cover the night shift for the weekend. When I got to work, I learned that I was covering for Nurse J. Turns out she got fired "after a number of noticable med errors." The DON had also posted a notice for a mandatory inservice to discuss med errors and patient rights. Rumors were also flying about other nurses that were either fired or suspended and the nurse giving me report informed me how I better make sure I have no holes in my MAR/TAR and make sure I double even trible check everything because management is cleaning house.

Yes they counted the NARCs at shift change together but the count was correct. The nurse did not pull the NARC that she signed she gave on the MAR. Which is a med error because its an omission. I do same as you mentioned,sign my MAR after giving the med and when I count with the other nurse, I look at the book and the bubble pack as we count. If I find a NARC not given , then I advise that nurse to correct it before I sign off for the cart.

Just wanted to clarify... the PM nurse signed the MAR that she gave the scheduled NARC. But when the night nurse checked the NARC count book, the last initials were from the day nurse. The PM nurse did not give that med. As for nurse j, she had access to the narc box bc we share that cart.

There are three hallways on each unit. During the day shift and PM shift, there are three nurses on the floor. At night, there is two nurses on the floor. Each night nurse takes a hallway and they split the middle hallway. Every med has the same key so every nurse can open any med cart and treatment cart in the building. Each med cart has a special NARC box and there is only one key that will open and each cart has a different key. So each nurse has their own set of keys for their cart. That said, at night, the middle cart keys are locked in the med cart. So "Nurse J" used her keys to open the cart and then took the keys out of the top drawer to open the NARC box. I did speak with the ADON this morning about her. I was upset that she medicated my resident w/o even discussing the situation to me and also about the other situations. The ADON had told me that another nurse had also complained about "Nurse J" medicating her residents as well and she assured me that she will personally handle the situation.

After four years as an LPN with 11+yrs as a CNA; I really do not think of my self as a "new" nurse but I am always learning and do not know everything when it comes to my job as a floor nurse in a LTC/Sub-Acute/Rehab setting but I also feel extremely comfortable and ready for any..any..situation. That said, I met my match last night. I worked with, at first, a very nice older nurse...we will call her "Nurse J"... Several situations came up during our shift last night that involved my patients and one situation that involved another nurse's patients. Situation #1... During report, the reporting nurse informed me that one of my resident's was still up in her w/c and did not want to go to bed. She reported that when staff approached her and attempted to her put her bed, she would become very upset. I didnt think it was a major problem, and thought eventually she would go to bed. "Nurse J" told me immediatly after report that I should give the resident an Ativan so she would go to bed. Being a new nurse to the facility, I did not know my resident that well. So I looked in her chart and saw that she had an order for PRN Ativan for agitation and her last dose was the day before and that she rarely needed it. At that time, she was sitting in her w/c, eating a snack. She is alert with extreme confusion. But no agitation noted. So, I let her be. I advised the CNAs to offer her to go to bed when they do rounds. As the night went on, she was becoming more and more tired and started to hum. But refused to go to bed. "Nurse J" told her she "needed" to go to bed and the resident told her "No..you cant tell me what I need." She was never at any point agitated to the point she needed a PRN Ativan. I documented in nursing notes that she was refusing to go to bed when offered. At 3am, I had another resident situation and I was in that resident's room for about 25mins. When I came out, my resident was no longer up by the nurse's station. The CNA at the desk said the girls were putting her to bed. I figured she had just finally became tired and wanted to go to bed. "Nurse J" came out of the med room and said to me that she gave my patient her "night pill" and is finally going to bed and called her a "stubborn ol lady". I was floored. I asked her if she was agitated and "Nurse J" told me she was just annoying and wouldnt stop humming. Plus she needed to go to bed. I looked at the MAR and sure enough "Nurse J" gave her a PRN Ativan for agitation. Whenever a PRN is given, it must be charted what behavior was noted on the back of the PRN sheet and "Nurse J" charted she was a "7 out of 10" agitated and was "disrubpting" the unit. I asked her if she documented in progress notes why the med was given (as required) and she told me that no, that it was my resident that I needed to document. I told her I was not able to chart on something I did not see. I am all about giving someone a PRN med...WHEN THEY NEED IT!!! This resident did not !! You cannot force someone to go to bed. She refused. She has rights. It really ****** me off that "Nurse J", imho, stepped over her bounds and did that. Situation #2 During report (again) , the reporting nurse told me that one of our older residents was in resp. distess and she wasnt sure what the next step was because she was a DNR. I asked if she called the doc and she said no. I asked why not and she said because she is a DNR. (really?!) I asked her if she knew what DNR means and she said yea..."do not do CPR.."(again really?!) I said ok..but we still treat. As she was talking, we were heading to the resident's room so I can assess the situation. She is a 96yr french speaking eldery lady with a hx of dementia, HTN, MI, COPD and DM. I entered the room and noted her laying flat in bed, and struggling to breath. She was on O2 via NC at 4L. I raised the head of bed up and put an extra pillow behind her. Her skin was cool and clamy. She was really answering my questions, just saying "yea". BP 98/50 HR 88 RR 24 and temp 98.9 .Lungs were noted with rhonci, sats were 85% with O2 at 4L via NC. I turned down the O2 to 2L. She had a PRN neb tx order for Q 4hrs. I asked the nurse when was the last neb tx and she stated she didnt know she had the order. ( smh at this point). So I gave her the PRN neb tx. Her sats improved to 95% but she was still, to me, in some sort of distress. Again, I really do not know the resident and do not know her baseline but something wasnt right with this resident. So I quickly phone the doctor and while waiting for the return call, the nurse and I finish report and the narc count. "Nurse J" had overheard all of this and went down to assess the resident herself. She came back and told me that is was "nothing" that she is "just dying" and there isnt really anything I could do because she is a DNR. I really didnt know what to say at that point. The doc called back and ordered stat labs, stat CXR, 1GM Rochephin Now, Duonebs every 4hrs and Z-Pack as directed to start in AM. Lab and xray results suggested pneumonia. MD updated. He stated he would be in first thing in the AM to see her and to call if any changes. "Nurse J " told me that I was making a big fuss over nothing, how I was just wasting my time. Situation #3 A nurse came from the other unit and asked what she should do about a noted med omission. She had a resident that is AAOX3, c/o of severe pain and stated to her that the previous nurse did not give her any 9pm meds, including her sleeping pill and pain pills. When she did request something for pain, she was given Tylenol. The night nurse noted that the PM nurse signed out in the MAR that the meds were given but did not sign out in the NARC book that the NARCS were given and the counts for the meds were correct. It was clearly obvious the resident did not get her scheduled NARCS even the though the PM nurse signed the MAR. I told the night nurse its a med error and she needed to follow the facilities protocal when a med error occurs. At the very least, give the resident something for pain and let the supervisor know the morning. "Nurse J" stated to just medicate the drug seeker and mind your business. If you report her, that is tattletelling and nurses are too old to be a bunch of tattle tellers. What would have done?

Suggest to the family to have him seen by a dermatologist. I have see this a lot in residents who have dementia and wondered my self if its a reaction from one of the meds or is it behavioral.

For LTC charting, here are a few common things she might be looking for (mostly for medicare charting/MDS) . 1) Is the resident alert and oriented x 3 or are they confused? 2) Do they require assistance with ADL's? If so, how many staff is required to assist? 3) Are they on an antibotic? If so, for what and is there any adverse reactions. 4) Did they take their meds and tolerated them during your shift? 5) Any dressings or treatments ? Even if you personally did not change the dressing, note the location and condition of the dressing. 6) Does the resident have a mid line or picc line? Did the line flush with or with out difficulty. 7) Check the resident's primary dx and make a note related to the dx. 8) Is the resident continent of bowel an bladder? Foley? Here is an example documentation for a resident who is s/p ® hip ORIF. "Resident is alert with confusion. Resident requires assist of 1 with all ADLs. Resident is up ad lib in w/c and able to move independtly in w/c throughout facility. Resident currenlty on ABT PO for UTI with no adverse reactions noted this shift. Urine noted to be cloudy. Temp 98.9. Resident denies any urinary discomfort. All meds given as ordered and tolerated. Writer noted dry, intact dressing to ® hip. Resident c/o ® hip and PRN pain med given x 1 this shift with effective results. Resident incontinent of bowel and bladder. Peri cares provided by 1 staff assist and resident is on toileting program. Resident is currently resting in bed with no s/s of pain or distress noted at this time. All safety measures in place." Here is another example: Resident is AAOx3 and is able to voice needs to staff. Resident admitted yesterday s/p total (L) knee. Dressing noted on (L) knee to be dry and intact. No redness noted. Resident is continent of bowel and bladder and reguires set up assist only. Up ad lib and currently in physical therapy. All meds given as ordered and tolerated. Writer encouraged resident to use call light to call for assist prior to transfers. Safety measures in place. One more example Resident is AAOX3, able to voice needs to staff. Assist of one with ADLs. Noted to have COPD. Lungs are noted with rhonchi, sats are 89-90% on 2L/NC, HOB elevated. Resident denies any resp. distress this shift. Noted to be in bed, watching TV most of shift. Family visited. All meds given as ordered and tolerated. Writer assisted resident to reposition in bed and enouraged fluids. Safety maintained. Hope this helps!!

I agree with the pp...you can also still go to community college and take the gen ed courses and common pre reqs while you are still searching your major. I wanted to be an fighter pilot when I was a kid...nursing never even crossed my mine. I started out as a CNA and continued my education. Good luck..

So, I started my new job today and was very happy with the nurse that oriented me. She was very informative with the policy and procedures and I noticed she was very efficient with her med pass. She asked if I felt comfortable doing a few tx's, meds and I took on a few tasks. I had questions and she was there to help. So what is my problem then? Well, I noticed by working thru my agency, going to different faclitilies for staff relief and by working full time in one place, that every place has a different way of doing the same thing and I think that is just kinda of silly. For example, in one nursing home, its policy to sanitize the BP cuff after each resident with a sanitize wipe but those wipes are not allowed on the cart, only on the treatment cart. Another nursing home says to sanitize the BP cuff after every 3rd resident. One nursing home we must clean the glucometer after each resident while another nursing home has a totally different policy. To keep my sanity, I have made notes and glance over my notebook when I am assign to a facility. I wish there was just a general policy for every place for the simple things that would save the nurses a ton of time. Its hard enough passing meds to 20-25 patient in the whole "hour before/hour after" ...add the extra time for cleaning each cuff its like....banging my head up against a brick wall.... okay..done venting ..thanks!!!

I work with Expicare Nursing Agency. They are pretty good...keep me busy!!

To me, as a nurse, if I had an order for a BP medication WITH PARAMETERS, then I would take the patient's BP and HR prior to given the medication. And I would do the same if a resident was also taking Lasix. What is happening, is that most LTCs are not just for patients who are older and at the time in their life when they can no longer care for themselves, but more and more LTCs are now with younger patients who need short term rehab or even long term care. So yes, it is possible to have a patient case load of 30 patients with vitals Q shift in a LTC setting. As far as using a wrist cuff, I personally wouldnt do it. Most of the time, I use the house electric unit but if I get an reading that is off, then I use my manual cuff.

So I am doing class room orientation this Thursday and Friday. I am assuming that I will get my new schedule during this time. My shift will be 11p-7a. I have worked this shift before and loved it. But that was years ago...prior to having my 3 younger children. Now I have an 9 yr old, 8 yr old and 7 yr old to look after during the summer. I will have some help from my sister but not every day. So my question for you guys is how do you manager working the night shift with kids at home? Also, do you come home and go straight to bed or do you stay up and go to bed later in the day? Any idea of your normal routine will be so very much appreciated!!! Thanks!!

I actually have considered MDS...did some training so I could cover vacations. I think I am gonna take this chance ...finish school and maybe work toward the goal of MDS or managing.... Thank you for encouraging words

The administrator called me and wants me to write a statement as to why I feel I was let go. Apparently after I left...things were said about the nurse manager and the DON and how they set nurses up to fail. I think I am gonna embrace my new job and make sure I cover my orifice!!!!!