Mama Jules

I've seen my share of all different kinds of family dynamics in my 28 years of long term care. And as a stepdaughter of a stepfather who had a godawful case of dementia along with almost every single kind of chronic illness you can name, I suffered through listening to him verbally abuse my mother EVERY DAY the last 5 years of his life. She had promised his "real" children she would never place him in a nursing home. Yet, they would not lift a FINGER to help her take care of a demented, incontinent, bilateral amputee. I am the only one of my mother's children that lives in-state, so it fell to me to help her; relieving her to get out of the house on some days, running her errands for her on others. I literally cringed every time I heard him yell and curse at my mild-mannered mother. He never slept at night, suffering from horrible sundowning, so the most sleep she ever got was trying to nap while he slept during the day. But he was a wonderful husband to her before he became ill. Now, on the other hand.... My mother in law became demented before she died and I was expected to take care of her, as she had two sons and one of them was just a plain old idiot. The other I got lucky enough to marry. :) She had NEVER cared for me; she thought her son had married "beneath" him, she thought I was a crappy cook, a crappy housekeeper, a crappy mother. However, when she needed medical advice, she didn't hesitate to pick up that phone or show up unannounced at my door.....guess I wasn't a crappy nurse since my advice was free. She constantly berated me about something I did wrong (according to her) waaaaaay before she ever developed dementia. I was 18 when we married, and I was over 40 when she first got sick. I put up with her verbal and emotional abuse many, many years before the dementia beast got her. My husband, after years of trying to "keep the peace", finally just stopped visiting her. He wouldn't allow our kids to visit her without us. He told me numerous times he'd had a miserable childhood, that she was always criticizing him and his brother, and even his dad, as well. He thinks that's why his dad passed away from heart disease so early. He said she had always been "difficult to love". I told him I found it rather difficult to not wish her dead. :) So, after she became unable to care for herself, my husband and I had ZERO qualms about placing her in a facility. I never lost a minute's sleep over it. Every time we visited, she offered to "leave everything to us" if we would just take her home and care for her. No ma'am. Not falling for that. In the end, the idiot brother agreed, got her to sign a financial and medical POA, took her to his attorney's office to put the deed to the house in his name, to the bank to withdraw all her cash assets and give to him, and then took her STRAIGHT BACK TO THE NURSING HOME. All this when she had been declared incompetent to make medical decisions. You just can't make this stuff up. I felt sorry for my husband as he lost half his inheritance and just was so tired of his family he didn't fight it. But, in the end, I laugh. I laugh because my MIL reaped what she sowed. I laugh because the idiot brother thought all that cash was cool; but ended up having to pay for her funeral expenses because she'd let her life insurance policy lapse. i laugh because the house was poorly constructed and he's had to spend a fortune in repairs. I laugh because the idiot brother married a shrew and a harridan that makes his mother look like Mother Theresa. I'm grinning now as I type this. I said all that to say, we long term care nurses, I think, are a special breed; we see all kinds of family dynamics, live through all kinds of family dynamics, and put up with some of the most unimaginable cursing, spitting, kicking, drooling, crapping, screaming people that ever lived. And that's just the employees!!

Thank you. I thought I was right....but you know every now and then a newbie comes along with a new perspective and makes me second guess myself. Do you have link to the page in the manual I could refer to? I know I've seen it in there, but I have scoured both chapter 6 and 8 of the (Medicare) manual and dang if I can find it.

I have many years of experience but right now cannot put my hand on the Medicare reg about qualifying stays. Here's my predicament: 01/09/2015: Resident admitted under Part A services after a qualifying event. 01/22/2015: Discharged from Part A after refusing therapy services and no longer any nursing skilled services provided. Met the criteria for intermediate level of care under Medicaid guidelines. 05/20/2015: Admitted to the hospital for surgery r/t non-healing wound (appeared after 30 window to re-skill had closed). 05/21/2015: Re-admitted to unit after a one night stay in a regular (non-observation) bed. 06/05/2015: Admitted to hospital for worsening of wound. 06/08/2015: Re-admitted to unit. ***What are the guidelines concerning when the 60 day spell of wellness (less than skilled) occurs? Will the break in stay on 05/20 preclude her from Medicare A benefits OR since she had 60 days of wellness prior to that stay, can we pick her up under her A benefits again?

I agree with the other posters that it may be time to discuss this resident being admitted to a lockdown facility. The problem is, at least in my state, the few places that have them stay full. I also agree with the poster who stated long term care facilities are not equipped to handle all geri-psych residents, yet here in our state, that's exactly where they are ending up. Your resident is a classic example of someone who appears to be moving from a lower stage of dementia to a higher one. They have just enough cognition to know what they used to do, who they used to be, but not enough to be able to care for themselves independently. In many cases, they think they can but actually cannot. The advice you got about redirection (allowing them to follow you, engaging them in conversations concerning their comments, etc) is very good advice. I have to question, however, if you having to perform tube feedings (which in SC, precludes someone from being allowed to stay in ALF unless they can care for it completely themselves start to finish; nor can they have a decubitus ulcer or surgical dressing) and other skilled nursing duties is really safe for a 1:40 nurse/patient ratio. You need help, sister. And fast. Also, have you considered asking your doctor about adding Depakote to this patient's regimen? I find its mood alerting properties often work better at combating behavior problems in dementia residents than antipsych med does. Just have to monitor LFTs ever so often.

I call out if I'm afraid what I have is contagious (i.e., fever, sore throat, chills, diarrhea, n/v) but not for headache, fatigue, soreness, general aches and pains ( I'm almost 50 with too many 12 hour shifts on cement floors). However, I have always been a strong advocate for separating general "PTO" days from actual "sick leave" days (the latter only being used when out 3 or more days with a doctor's excuse). My employer lumps all PTO days together, but continues to stick to his guns concerning the above mentioned qualifying events for "sick pay". In other words, if you schedule PTO ahead of time for purposes other than being sick, it is granted; but if you generally feel sick enough to stay home but not sick enough to go see a physician, you cannot get your PTO time authorized. What is happening is that staff is catching on and going to ER's or stand-alone clinics where the physicians are all too happy to give them work excuses and taking their money for what could be managed with a day or two at home. I personally couldn't care less, because it's a crappy policy (I do hate that some of our employees that make just above minimum wage have to pay for a doc's excuse) but I can never bring myself to do it. And, I don't have co-worker guilt. I am presently employed as the only full time MDS coordinator so my work waits on me to return. I've just never been able to say I'm sick when I'm really not, and I HATE coming back to an overloaded work desk. :)

Did you even read my post? He was not "near" the nurses' station, nor was he in the "official" break room. He was across the entire PACU floor, in an empty nursing station, where he clearly couldn't hear the call system. It wasn't "quiet". A call bell was alarming at the nursing station, and he wasn't hearing it because he was yards away from said nursing station. And, he was playing a game, because I have same phone, same game. I know what it looks like. I am in no way saying breaks don't need to be taken when and where they can on a stressful unit; and I've no problem with someone using their smart devices on a break. Not at all. I am simply advocating that a PACU might not be the best place to bring a smartphone if you cannot refrain from using it when you're needed.

Well, you have a point, VANurse; maybe I was overly emotional. After all, I was only concerned that my husband not have to undergo unnecessary treatments for avoidable post-surgical complications. You would have reacted differently? You're right, one nurse breaking the rules doesn't mean they all do; but generally in a PACU, patients are 1:1 or 1:2 for a reason: they need pretty significant observation to ensure proper recovery. I was speaking to things that can happen when people get engrossed in their phones at work, and how that could, if allowed without checks and balances, affect patient outcomes.

As a sufferer of plantar fasciitis, freezing a water bottle or two and rolling it under your feet at the end of a shift, or a walk or run, helps as well. Also, there are some terrific you-tube videos illustrating ankle exercises that can strengthen the muscles surrounding the ankles, which in turn will ensure better stability when walking, running, etc., which also can aggravate plantar fasciitis.

Mine is (coming from a LTC perspective) hearing nurses tell inquiring family members, "That's not my patient (or resident)", and walk away. No, they may not be under your direct care, but in my mind, it is ANY nurse's responsibility to help family members get to who they need to see, or the information they are looking for, or their family member taken care of. I've heard nurses tell residents who simply want water, or a snack, or directions to the dining hall, "go ask YOUR nurse". One could simply say, "Let me see if I can find someone who can help you". To imply that you don't know anything (at least to me), or don't want to do anything to help makes nurses appear lazy at best, incompetent at worst.

I'm with you. I work as a Medicare Reimbursement Specialist in an LTC facility. I have my own office, but I still leave mine OFF in my drawer or purse and cut it on only during breaks. My husband recently had a TURP done and I was staying with him in PACU. Anyone who knows anything about these procedures knows CBI is necessary for 24-48 hours post op to ensure against clotting off and blockage of the urinary stream. When hubby's irrigation solution (running by gravity) got low, I pressed the call button. No response. This was around 10 pm, so evening shift. I waited around 10 minutes, and noticed the irrigation solutions was VERY low. I went looking for his nurse. Where did I find him? Around the corner, at a nursing station that was not being used on the other side of the PACU, in the dark, playing a game on his iPhone. And yes, I knew it was a game because I walked up behind him and could see the screen. By the time I (and he) got back to my husband, his irrigation bag was bone dry, and I was in tears (mostly, I think from exhaustion...it had been a very long day). He was apologetic, and fortunately nothing came of it, but all I could do was think...this is PACU....what if someone was coding, or bleeding out, or...... I was very unsettled and told this nurse my concerns. His reply? "I thought the bag would've lasted longer".

Yes, I usually do; there are lots of reasons residents receiving tube feedings may develop dehydration; at the very least they are at risk simply because they are dependent for their hydration needs. I have always been of the mindset that having a care plan that is not necessary is better than NOT having one that is. I've never seen a survey care plan tag for having an unnecessary care plan. I have seen them issue citations for NOT having a care plan for a particular problem. What I normally do is combine the risk for dehydration with the risk for fluid overload and complications at the insertion site all on one care plan.

Login to Excelsior. Your home page should come up. Click on "Microbiology Practice Exam" When the Blackboard opens, click on the exam. Click on "taking and reviewing your practice exam". In the table of contents, scroll to number 8, practice exam Form A, and click the link. Click on "click to launch" Click on "begin" The page that comes up will tell you that you have already completed the test, and will ask you if you want to see all attempts. Click on "view all attempts" Under your "calculated grade", you will see your score. If you click on the score, it will open up the test questions. It seems to me to be going around your elbow to get to your thumb, but that's the only way I know of to see your attempts.