RN/LVN Ratio Acute Care

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Unsure if this is the correct subforum to post this in, but wasn't sure where else to go. If there's a more appropriate forum, I'll repost it there if mods tell me to.

I work at a small, rural, "critical access" hospital in California. The acuity of patients is relatively low, there are many LVNs employed here doing direct patient care as well as support roles like wound care. This is technically a Med-Surg floor (says so on the door and management refers to it as such) but we have many "swing" patients which are basically rehab patients similar to what you'd see in the "post acute" or rehab wing of a nursing home (PICC lines, long term abx, PT/OT, wound care).

The issue is that the boss has formerly insisted we have at least 1 RN for every LVN, and not allowed us to do schedule swaps before do to this, but recently I got scheduled where I was the only RN on the floor for all the LVNs (4 of them). It's not that the LVNs are bad nurses or incompetent, its that I don't think this is legal, and its a real chore to hang everyone's antibiotics for them while I have 5 patients of my own. I confonted the manager and she cited title 22, which she claimed enables her to have only one RN on the floor. The section she highlighted on page 42 of Title 22 California Code of Regulations Division 5 reads:

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Licensed vocational nurses may constitute up to 50% of the licensed nurses assigned to patient care on any unit, except where registered nurses are required pursuant to the patient classification system of this section.

However, it also says on page 46 that

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(m) A rural General Acute Care Hospital as defined in Health and Safety Code Section 1250 (a), may apply for and be granted program flexibility for the requirements of subsection 70217 (i) and for the personnel requirements of subsection (j)(1) above.

Does this mean section (i) and (j) of the same document? That refers to administrators not being counted as charges or something, or is there some whole other document or part of the document I need to look up?

It reads to me like a pretty clear cut mandate on a maximum of 50% LVNs on the floor. Am I wrong?

The manager got frustrated and scheduled a meeting with me and the DON on Monday 01/20/2020 at 14:00.

Thanks for reading this thread! I'll be checking back when I can!

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I believe you are correct.

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Here is the document:

http://www.nurseallianceca.org/files/2012/06/Title-22-Chapter-5.pdf

Begin reading on pg 41 at the heading §70217. Nursing Service Staff

The following statement: "Licensed vocational nurses may constitute up to 50 percent of the licensed nurses assigned to patient care on any unit, except where registered nurses are required pursuant to the patient classification system or this section" is found in the 5th paragraph of the first section, section (a).

Pg 46 contains the other statement to which she is referring, in section (m). It states, "(m)A rural General Acute Care Hospital as defined in Health and Safety Code Section 1250(a), may apply for and be granted program flexibility for the requirements of subsection 70217(i) and for the personnel requirements of subsection (j)(1) above."

It certainly isn't clear that pg 46 is referring to section (a) on page 42.

Maybe she is allowed to finagle things based on the swing bed status. I couldn't find much information about that, but I wouldn't be the one to bring it up. They either know what they're talking about and can tell you or else they're making it up.

On 1/17/2020 at 5:07 PM, frenchxtoast said:

I don't think this is legal, and its a real chore to hang everyone's antibiotics for them while I have 5 patients of my own.

**You should carefully read §70215. Planning and Implementing Patient Care (beginning on p 40) to better understand the extent of your duties in this situation. It is significantly more than just hanging the abx.**

Good luck w/ your meeting

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12 hours ago, JKL33 said:

Here is the document:

http://www.nurseallianceca.org/files/2012/06/Title-22-Chapter-5.pdf

Maybe she is allowed to finagle things based on the swing bed status. I couldn't find much information about that, but I wouldn't be the one to bring it up. They either know what they're talking about and can tell you or else they're making it up.

**You should carefully read §70215. Planning and Implementing Patient Care (beginning on p 40) to better understand the extent of your duties in this situation. It is significantly more than just hanging the abx.**

Good luck w/ your meeting

Thank you so much for this useful and informative reply! Really appreciate the PDF link. I rescheduled my meeting with the DON to 01/29 due to catching a sudden cold last night while at work. Felt fine in the morning, throat was burning and I was dizzy and fatigued by 16:00. So glad I didn't try to go to work today.

I've been googling around, but I'm having trouble figuring out exactly which agency I can call to report this type of thing, or ask questions to regarding it. Ideally, someone official could give me a clear answer about this before the meeting.

Any ideas?

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UPDATE: I found the phone number for the California Department of Public Health District Office for the area I work in. Would this be the correct place to call regarding this?

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UPDATE: I found the California Department of Public Health website and clicked on the district offices link (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/DistrictOffices.aspx), from where I found the District Office for my county's jurisdiction. I called them, and an official told me that staffing > 50% LVNs on the floor is illegal regardless of it being a critical access hospital or swing bed status. He also said the ratios must be on a day to day basis, they cannot be averaged over a time period. Additionally, critical access hospitals do have one exception: they are exempt from the rule forbidding an "administrator of nursing services" from serving as charge nurse or performing direct patient care. It's unclear if they can be counted in the ratios or not.

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UPDATE: I called back again, and apparently the floor manager can serve as a charge nurse, but the DON cannot, unless the critical access hospital applies for this "flex" and has it approved, and posts the flex nexts to the facility license. However, if the floor manager is being counted among the RN/LVN ratios, the manager can be held legally liable for the LVNs care, and is supposed to be doing patient care IE hanging IV abx, managing PICC lines etc.

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FINAL UPDATE: I had a meeting with the DON and floor manager and they agreed to hire more RNs, which they did. Ratios have been in compliance lately, but now they are saying they can go out of compliance again due to COVID-19, including having us take care of > 5 patients at a time. Making a new thread on this subject.

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I'm impressed with the actions you have taken instead of just saying "it is what it is" like so many people I hear.

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