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Medicare Reimbursement; MDS/RAI
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OldGrayNurse has 27 years experience and specializes in Medicare Reimbursement; MDS/RAI.

Nurse of 27 years, wife of 32 years, mother, caregiver, amateur photographer and writer. Follower of Christ thought I live a far from perfect life.

OldGrayNurse's Latest Activity

  1. OldGrayNurse

    All staff matter :)

    I find, in many instances, it is simply a matter of perspective; ER nurses don't understand LTC's don't have a doc on site 24/7. In most cases, they round monthly, and you bet your sweet tootie they aren't going to come out to see someone sick other than if they are on site for rounds. They are quick to tell you to send them to the ER. Hospital nurses, unless they worked LTC in the past or work part time at one, in general lack understanding of how things work in a long-term medical facility. And, I might add just so I don't get whacked, vice verse. When we work in one institutional setting, we tend to get tunnel vision as to how things work and forget all nurses (and the places that employ them) are not alike. Heck, I just today had a case manager try to send me someone straight out of CVICU. We don't accept patients coming straight from a specialized unit (with the exception being geri-psych) because they tend to be still a tad more acute than a nurse working 1:22 (or 1:44) nurse to patient ratios can safely monitor. Hospital case manager was new, hospital nurse was new, hospitalist doc discharging wasn't acclimated to long term care, and you have a perfect cluster..... I'm trying to say....it's easy when you're working in an ER to assume you have a practitioner you can just summon when you like; and it's easy when you work in LTC to assume the hospital knows your long-standing rules. Kudos to you for keeping your wits about you and not trying to crawl through the phone Nurse Jackie style and throttling her. Still, she shouldn't have jumped to conclusions. I have often wished, in my almost 30 years of nursing, that nurses could kind of "shadow" one another in a completely different setting a day or two a year just to get the gist of how other settings flow. I, personally, would love to "shadow" the EMT/paramedic/medical transport personnel a couple of times to find out how all my patients get those nasty decubitus ulcers on the short ride from the hospital to the nursing home.....and vice verse.
  2. OldGrayNurse

    Co-workers mad that you're going to school

    I have experienced this same thing. Paradoxically, it was my DON who suggested I go back to school because it "would look better for our facility if all our administrative nurses had BSNs." Basically, I was given a two year time frame to acquire my ADN, and another three for my BSN. This was during my annual review. Mind you, they asked me if I would be interested in distance learning through Excelsior College and "highly recommended" I pursue it this way so that "my hours of employment could be maximized". Now, every single time I ask for hours off for an exam, or because an exam coming up is super hard and I feel need extra study time, I get a "look" and a sharp intake of breath and a "I'll see what I can do" attitude. I wouldn't be so critical if I had decided to return to school on my own. I was pretty much pressured into it, and now feel as if I have ZERO support where my Admin and DON are concerned. And my fellow nurses? They think the time I spend at work behind a desk (I'm a Medicare Reimbursement Specialist at an LTC) is play time and that I should be spending my time out on the floor helping them do their job. Because my job isn't important, and because it isn't fair that I don't have to work holidays and weekends. (Because I am considered administrative personnel). Never mind that I have to cover the floor when we are short (which puts MY work behind), that when I am in a crunch due to a large number or part A admissions I DO work nights, weekends, and holidays, and that while I can cover the floor when they are short of staff nurses, no staff nurses here can do MY job when I get behind, nor does admin offer me the help of extra nurses when I am in a bind. Basically, I feel I got bullied into going back to school because, while no one said outright I could lose my job if I didn't, it was very much implied. And now, along with being forced to go back, I feel I have no suppport when I need it the most. I should also add, I was offered tuition reimbursement ONLY if I signed a five-year contract to work for them exclusively after my degree, which started after I passed state boards and became an RN, not while I was in school. Hell to the no. I'm paying my own way, on top of feeling as if I have no support and no choice.
  3. OldGrayNurse

    Why are nurses so backbiting?

    I've been an LTC nurse for almost 30 years. I've worked with the NETY attitude; I've worked without it. I've worked restaurant server, factory, and other non-nursing jobs pre-nursing school that had the same attitudes of what the OP called "backbiting". I don't think it's exclusive to nursing, but nursing IS one of those career fields that happen to be overwhelmingly same sex. As a female (please don't sic the NOW on me) I can say looking back, I do feel women seem to have this attitude more than men do. And women seem to have a "pack" mentality, IMO, more than men do. The men I worked with were aggressive, full of themselves and testosterone, sure; but they did whatever they had to do face to face, confrontation-style, and then got over it. The women I've worked with were more sneaky, snarky, waaaaay more dramatic and could hold grudges for AGES before letting something go. Whether it's in the genetic makeup, learned behaviors, etc., it's something I never practiced or understood. If I've got a problem, my tendency is to "hash it out" honestly and quickly, and move on. I can't tell you how many times I've been ostracized for not participating in gossip, or for not ganging up on a certain co-worker because "she hurt my friends' feelings" or got what others thought was an undeserved promotion, etc. I do believe management style has everything to do with it, and where I am now, laissez-faire is the name of the game and the backbiting, snarking, throw each other under the bus mentality is RAMPANT. If I were still a floor nurse, and not working in admin, I would not be here. But I have an office I can escape to, an office co-worker who is similar to me (tries to stay away from all that) and that makes it bearable. Management has been asked several times to address this, but cannot, basically because she is one of them. She is paranoid someone wants her job, terrified someone more qualified and skilled will replace her, and so she lets the floor nurses and staff basically do whatever they want, and then runs to "put out fires" because it makes her feel more secure that she'll keep her job for addressing issues (that she created in the first place, lol). She actively promotes disharmony, because she has nurses that will go to her and deliver all the floor gossip and keep things stirred up so that she can get personally involved and "solve problems". None of the floor nurses work together; they even do petty things like deliberately call in when they know they will be working with a certain person, or ignore family members whose resident is assigned to the other nurse on that floor who is at lunch, away from the hall, etc. I think our DON does this because it gives her job security. (Who would want to be DON for a bunch of nurses who call in whenever they want, do whatever they want, and are never punished for it?) I didn't mean to turn this into a "you think you've got it bad" personal story. Just venting I guess. And, yes, the posts are full of these kinds of stories. What's the answer? I don't profess to know; but I wish someone would pull my administrators head out of the sand and his butt out of his office and show him all the stuff going on. But, as they say, "There are none so blind as those who refuse to look."
  4. OldGrayNurse

    Excelsior math

    Grab the CLEP College Math workbook off of Amazon. Do those exercises and the one in the Study Guide from EC, and you will do fine. I barely cracked either book and made a C, as I was pressed for time. If I had applied myself I would've done better, but I'll take that C, as I despise math.
  5. OldGrayNurse

    Excelsior math

  6. OldGrayNurse

    Just started excelsior!!

    I ordered the CLEP College Math workbook. The problems are similar to what you will find in the Excelsior study guide; I used this and the practice tests by Excelsior and passed. Here is the link to the CLEP math workboook. https://clep.collegeboard.org/exam/college-mathematics
  7. OldGrayNurse

    Article NY Times! Spot on...I think so!!

    An EMR program that was downloaded into our computers and implemented by our BUSINESS OFFICE MANAGER with NO formal training from the company, and the BOM as the ONLY PERSON allowed to customize is what we nurses are all having to deal with where I work. It is a faulty system full of "down-time", assessment forms full of unnecessary demands, and completely non-friendly for older nurses who may not work much on a computer outside of work. It was cheap and the BOM talked the admin into it because he knows nothing about computers and doesn't even have one in his office.
  8. OldGrayNurse

    Is Your Workplace Healthy... really...

    I agree; however, with insurance companies requiring healthier BMI's, no smoking/smoking cessation, body mechanics workshops, etc, for better-priced plans, employers should be actively seeking to at least try and offer something. My employer considers a paycheck the only incentive you need, and couldn't care less how overweight, in poor physical health, or unhappy his employers are. He is a staunch way, way, way to the right conservative furious over what he sees as "socialist" government interference with the way he wishes to run his company (he inherited it) and is doing everything he can to personally "thumb his nose" at the federal and state governments whom he insists is the blame for him having to provide ANY benefits. (He provides an employee-only "fake" health coverage plan that is actually a catastrophic coverage plan in nature, of which he will not hesitate to yank from you without notice if you miss more than four pay periods a year of working full time hours). He owns the snack machines and is personal friends with the vendor, who only places high sodium, high fat, high sugar, processed and EXPENSIVE foods in them. He stopped everyone from leaving to go get lunch and forbids deliveries from local places. He says it wastes too much time. Yet his employees often work twelve and sixteen hour shifts at the time, and he gives them zero consideration for pulling extra shifts. He cut costs so far back in the kitchen that the food is crap. AND, you have to buy it, too. It's not made on-site; There are NO fresh vegetables or fruits. Even our eggs for breakfast come in a big milk carton (eggbeaters...even for those who don't have any cholesterol issues). Everything is either brought frozen and ready-made or comes out of a can. There are no discounts on our health policies, either, given for those who weigh less, or don't smoke, or who regularly exercise. It's an LTC in a rural area, so a lot of the employees are grateful just to not have to drive into the city. Read my earlier post: he didn't even want ME (who has a desk job) WALKING FROM MY OFFICE TO THE OTHER END OF THE FACILITY FOR ANY REASON!!! He said any info I needed I could pick up the phone and ask for. (SMH) I am aware he doesn't have to offer any of these things. I am aware I have a desk job and need to produce while I am there. I do a good job, put up with a ton of attitude from people who USED to like to work here but don't any longer (see above), and I make money for him. I bring my lunch every day in a cooler and don't drink sodas. I have an elliptical at home and use it regularly. But every now and then, if I forgot my lunch, or didn't have time to prepare it, I'd like to know there is something I could eat that didn't cost me my entire daily caloric allowance in one meal. I'd like to be able to say, use the treadmill in the therapy room after hours if I'm going to meet friends in town later without driving 40 miles in the opposite direction. I'd like to be able to payroll deduct some athletic shoes or hand weights if money's running tight. (can't do that either, for some reason). I am saying that if he wants to continue to make a profit, he needs to see what is happening in this country with health care, get out of the eighties, and try something, anything, to keep the employees he has versus constantly training new staff (which he doesn't somehow understand costs more money because he learned from his father "nurses are a dime a dozen"- yes I've heard him say it- but doesn't understand GOOD nurses are NOT a dime a dozen). If he's not willing (and clearly, he's not) to offer 401Ks, incentive bonuses for extra hours/shifts, reasonable, affordable insurance, tax-deferred medical savings plans, etc., I think the least he could do is make it a tad easier to become a little healthier. Maybe it could improve the working conditions around here to the point where I at least don't take my life into my hands by asking the staff questions about the residents. :)
  9. OldGrayNurse

    Just started excelsior!!

    I just kept working the problems in the workbook and the study guide over and over. I am rotten at this kind of math too. There are no "medical math" questions per se, which I can handle; it's a lot of probability and statistical questions. Honestly, I was never happier to see a "C".
  10. OldGrayNurse

    Me......Me....Me : A Sense of Entitlement

    Yep. My husband (cancer patient at a major university hospital) just got his Press Ganey survey in the mail today. Asked me what it was for. Two hours into the rant, he regretted asking.
  11. OldGrayNurse

    Me......Me....Me : A Sense of Entitlement

    Stars, it is unreal how different it is now; I started out in LTC, went to rural health for a number of years, had a daughter that wanted law school so I came back because they do manage to pay well for the most part (or at least better than office/clinic work). It is an insane and asinine idea to mandate a "home-like" environment in these places and put forth such a demand on already stretched-thin staff. Our residents are waaaaay more acute than when you and I started out, would you agree? We are getting residents with PICC lines, Bi-Pap, C-Pap, wound-vacs, porta-caths, TPN, almost everything but vents. We haven't breached that one yet where I work, but by God, if Medicare manages to figure out a way to mandate it and will pay for it, my facility will do that too. And relegate minimal staff with minimal experience to take maximum care of them. I have never regretted my decision to become a nurse more so than now. What is even sadder, is that I'm in school to get an ADN, because my employer has decided I now need to be an RN to do the same job I've been doing for 11 years. (MDS). Ugh. I know everyone should want to advance their degree, but honestly, I have AANAC certification, I have Medicare Boot Camp certification, I keep up with the regs and guidelines, and do everything within my power, within the boundaries of ethics, morals, and the law, to contribute to my employer's wealth (she says with tongue planted firmly in her cheek). I'm not knocking one's desire in advancing their education; but it seems more and more that nursing has become about the degree and not about the experience. I just wish nurses didn't feel pressured to at the insistence of their employers (and the BON and federal regulators in some instances) because it looks good on paper. I really hate we have all become so obsessed with "magnet" status that many have become dissatisfied in their chosen career. Okay, enough of the vent. Thanks for responding to my post! See you around.
  12. OldGrayNurse

    Me......Me....Me : A Sense of Entitlement

    Working in LTC, you often see a sense of entitlement more so in the family members than in the actual residents. Anyone who's ever worked LTC knows your two largest medication passes occur b/t seven and ten in the morning, and seven and ten at night. Our nurse to resident ratios are larger, and it often takes all three hours to just do a medication pass appropriately; never mind if you have resident going south, or a new admission/re-admission, short-staffed on CNA so primary needs have to be attended to. This, in all my 25+ years of working in this field, is when every family member who's in the facility wants your attention NOW, or is calling to see how mother is. No matter how many times you explain these hours really need to be avoided for minor/trivial details that can wait, they want you to STOP right then and take care of everything from the "Mother's pink gown is missing" to My grandmother's roommate has stolen her cookies I brought her yesterday". While these are valid concerns, they are not A)life-threatening or B)time-dependent. If the pink gown is gone, me stopping to look for it down in laundry when she has other gowns to wear is not a priority. There is also a pervasiveness of entitlement where accomodations are concerned in general. Family members are becoming more and more demanding of a nursing home being like their actual home. We are mandated to become more home-like; the powers that be in our government think residents should have more control over their setting and a SNF should be less institutionalized. While it's a wonderful concept in theory (after all, this is usually the last place many of them will call home), it is a pie-in-the-sky mentality to think management of for-profit facilities (as most are) will ever comply to hire more staff for attending to things like providing the resident the choice to bathe whenever they want (there is a schedule for a reason-if your CNA has eight residents to get out of bed, dressed, and fed by ten a.m., all of them cannot bathe at seven just because that is when they are used to getting one. All of them cannot have her running to the kitchen for their breakfast every half hour because one wishes to eat at eight, another at nine, another wants to have a "light brunch" at eleven). There are family members that request utterly ridiculous things like "make sure my mother doesn't eat margarine on her toast but every OTHER day" (actual true story-because that's how she did it at home to maintain her figure and never mind that mom is demented, refuses to eat at times and actually is at a healthy weight) and "Dad gets upset when we visit so if someone could just sit with him a couple of hours after we leave...." and will NOT hesitate to report your behind to admin if you dare suggest it may be worth your while to limit mom's gowns' colors to pink if that's her favorite and it will distress her not to have it or that if we have volunteers here that day someone will be happy to sit Dad but our staff cannot focus two hours on one resident and ignore their other seven. I was actually reported once because a family member complained to me that her mothers 75 dollar silk gown was ruined in our laundry and she wanted to be re-imbursed; I simply suggested she not buy anything that cannot in a regular wash/dry cycle or either take mom's laundry home to be done. I was rude, impudent, and unprofessional. The admin (who caters to anyone with a private pay account) had the nerve to write ME up based solely on her word regardless that I had witnesses that voluntarily testified to management my behavior was neither. This is what we are dealing with in the twenty first century folks. The greatest generation is dying off, and the baby boomers are replacing them and the generation X family members are not happy with just having someone to provide competent medical care. They want (IMO) someone who will provide that medical care, coddle them, wait on them hand and foot, tell them they are right to demand immediate and subservient attention (and tell them they deserve it); admin would like for you to do all that, with no additional resources, and no additional remuneration for doing the jobs of the nurse, the doctor, the social worker, and the patient representative, and most especially, no support.
  13. OldGrayNurse

    Question about cna

    Sorry, OP. You didn't speak of them deliberately doing things that put residents in jeopardy in your first post. That's one thing that's not up for negotiation. If they are doing that, it's actually illegal, and you need to warn them and then write them the heck up. Not cool at all. And your supervisors need to be informed immediately. As the direct supervisor for these CNA's you can be held liable for injuries caused by will neglect, no matter it wasn't YOUR neglect. Safety is a huge deal, and had I known that from your original post, I would have said DO NOT tolerate that particular kind of disrespect at all. Never. Not even a little. Do something about it NOW. Today.
  14. OldGrayNurse

    Question about cna

    Sometimes it's a matter of perception. Some CNAs, for reasons unknown to me, actually have a harder time following the leadership of nurse they know used to be "one of them". It could be that you are unknowingly putting out an inexperienced and unsure vibe; they may feel as if you're not capable of taking care of anything that may come up and they think they will be the one blamed for not "catching" someone going south. Mind you, I'm not saying you are, only suggesting a reason. It could also be the exact opposite. Maybe you are brimming with so much self-confidence it is off-putting to them. Sometimes it is simply a personality conflict. Regardless of the reason, if you don't garner their respect, you will have a difficult time trying to supervise them. Have you tried a brief informal team meeting at beginning of shift? Have you thanked them all at the end of the shift for their hard work? Have you made it clear to them you are there to help but that you have your own tasks to complete and that while you will gladly assist them when you have time, your tasks have to be completed in a timely manner as well? Do the other nurses have this problem or is it just you? If it's the former, it's time for you all to get together and speak to your DON. If it's just you, you're going to have to figure out why they treat you that way but no one else, and build your solution from there. I once had the pleasure of working with a CNA who had a huge chip on her shoulder where nurses were concerned. She truly had the impression that my job was solely to assist her with whatever she needed, and would berate me loudly in front of the other CNAs, tell me to "do it myself" if I asked her to do anything she was within her scope to do, and disappear for a half hour at the time and tell no one where she was going. She did this to all the nurses, except when the admin or DON was around. My management was no help; they thought because she had been there forever she was just "colorful" and "treats everyone like that", and that was okay. One day when she hollered (literally) for me to come to the room and help her turn a bedbound resident NOW, I simply closed my Med cart, walked over to her, and handed her the keys. She stood there with her mouth open as I said, since you think I don't have anything to do today and you run this hall, YOU go pass out the rest of the meds to the residents. After a beat or two of her just standing there glaring, I took the keys back and told her we all had jobs to do, and just like she wanted to do a good job, so did I. And that meant I couldn't do both mine and hers anymore than she could do both hers and mine. The rest of the day, I asked her to come in with me and help me with every single treatment I had, no matter if it was just a bandaid. I wouldn't budge until she stopped and came. Anytime she ignored me, I just kept calling her. Although she never did like me and would still at times give me some nasty looks or mumble under her breath, she was easier to work with. In my 20+ years of LTC, I've had some wonderful staff experiences and some horrible ones. I've been able to identify exactly why only about half the time. Good luck! [emoji4]
  15. OldGrayNurse

    Seriously overworked

    I don't know what state you work in, but be careful following the advice to quit and find another job. In my state, hospital are attempting to gain magnet status and no LPNs are being hired, period. Most I know are relegated to either LTC (good pay but higher stress) or physicians offices (lower stress, better hours, but also lower pay). There are no regulations as to specific nurse to patient ratio in LTCs, only recommendations put forth by DHEC. They do exist for direct care (in the LTC, that's the CNA). There are regulations as to overall staff ratio (CNAs, RNs, LPNs, RN Supervisors) per number of filled beds, but admins are great at fudging the numbers in paper. For instance, if your grooming techs, who only work in the beauty shop doing hair are licensed CNAs, they can be counted in the ratio and the SNF would still be in compliance, despite being short on the hall. I am the Care Plan Coordinator, but my DON won't bat an eye at counting me in the hall staff nursing ratio. I said all to say, it's not unusual to be assigned that many (32 for one nurse) residents in my state. Normally, we try to stay 1:22 during the day, but legally it can go as high as 1:44. That's too much to provide good quality of care, and although the state recommends but does not mandate a lower ratio, they will be quick to cite your SNF under that tag anyway. They get away with not having to enforce it, but get to tag you for it if they find any care issues during inspection. I agree with you that it is too many, and it does suck big time that SNFs are allowed to get away with it, but I'm just warning you, you may find yourself in that same situation wherever you go, depending on your state mandates. Could you perhaps, do some quick research and pull together some care issues that may get tagged during an inspection that would be a direct result of high ratios? Skin issues, poorly controlled blood sugars, weight loss, UTIs, are things that are consider a result of poor quality of care if they show a "trend". Also, could you suggest hiring a staff member who might like to work alongside you and split the hall for the first eight hours only? Some older nurses like the idea of the eight hour shift. Might be worth a shot at permanently getting some help. Good luck!
  16. OldGrayNurse

    The holidays and legal issues

    Thanks to all for some good advice and interesting talking points. I've decided I either won't make homades or just one so I can include the recipe. I will also change my note to simply wish them a great holiday. There's nothing stopping me from asking God to bless everyone who receives the gift as I'm making them up. [emoji4] After all, He knows the heart!

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