Safe harbour or not

I am a charge nurse w/i a LTAC facility that has seen changes in staffing/patient ratios with increasing staff turnover and increasing use of agency nurses.

The changes mostly stem from changing Charge Nurse to a Team Leader Resource position allowing him or her to take patients while coworkers= LVN's can now give more of their own IV meds, make rounds with Doctors, chart checks and in general more of the Charge Nurse responsibilities.

Plan hasn't fully been implemented and not everyone has taken class training, which brings me to last night ,coming into work.

1) Staffing was done by CCO and not communicated to floor so assignments had to be redone. R.N., and two LVN's and one CNA for 14 patients and 2 admissions.

2)One admission arrived 30 min prior to shift change, moderate acuity, restrained=encephalopathy/restless/garbled speech Spo2 89% and wet.

3) Admission #2 arrived at shift change and more stable.

4)I am Charge Nurse and knowing the patients, take four ,giving my LVN coworker each 5 + 1 admission. I feel this will be safest after conferring with House Supervisor that we can not pull a nurse from another floor, the House Supervisor states she is unable to help with the admissions or do Charge because Unit 2 Medsurg requires her their due to a more heightened situ with new R.N. doing Charge and only 2 LVN's with 23 patients. Opportunity for nurse to be called in for help refused by House Supervisor.

5) So this leaves me with Charge, 4 patients of moderate acuity, assisting 3 Doctors at beginning of shift, thankfully a happy outcome with problematic family who requires>30 min teaching, IV meds are done by Charge for LVN's except for Reglan ,Saline, Unit Clerk is utilized on ICU to input M.D.orders for my review. I write out and input all meds for new patients and formulate MAR for LVNs as well as override their meds through the night to provide the medications for the new patients.Chart checks on all patients and R.N. assessments on patients dayshift not able to do=4 plus my four. CNA/RN Report sheet for oncoming shift.

6)I talk to House Supervisor at beginning of shift invoking Safe Harbour based on not being able to recieve additional help for the next 3 hours of high activity and a new patient that hasn't been stabilized yet, DX stroke with HBP requiring intervention to acquire prn antihypertensives. She calls her supervisor=CCO whose response is to make sure assignments are safe but she is not going to change anything.

7)3 hours later, patient removes his NGT, 2 patients saved from falls-one by bed alarm and the other close vigilance, delayed medications on the new patient w/o adverse outcome and no variance, omission of med during daytime for Lasix 40 IV q12 x 24 hours on a CHF pt caught and variance written, HBP with frequent monitoring stabilizing and I enlisted the wife to stay overnight with her encephalopathic husband who is restrained based on this being a new environment and importance of her voice and familiar face over the next 24 hours which she agrees to.

8) CCO comes in at 2300 to round and all has quieted down and her assessment of the unit after a 10 minute stay is "Everything looks fine"

9) Should I choose to follow through with Safe Harbour paperwork. There was no major adverse outcome. I do not fully understand the law but have read about other R.N.s being retaliated against from their employer and weakness of the law in the state of Texas in itself.

10) I still may see retaliation from my employer Monday from initiating this action and their attempt to misconstrue my good faith at keeping a safe environment....especially if I don't fill out the paperwork.It appears the decreased staffing will continue in an attempt to force staff into the new roles even though there hasn't been a successful time span alloted for implementation. I have told my co-workers that we can't operate this way again next Monday and its time to embrace the change with my additional reassurance to assist them to learn their new roles. Their attitudes aren't favorable and resistant

11)Please assist with insight and any helpful suggestions...House Supervisor in the past has helped to overlap responsibilities on the unit necessary to stay caught up but is now being told not to do charge functions to promote changes.....Thank You

12) Form was edited to clarify and impart accuracy and definitely not all inclusive...9/29/07