Scope of Practice for professional nurses in Assisted Living

[Malia BSN, RN]

Hi everyone,

I am looking for information on the scope of practice for LPNs/LVNs/Director of Nursing in ALFs. Sorry, my story is not so short. My mom is in an ALF in Virginia. 2 weeks ago she fell there and broke her kneecap. Luckily it was non-displaced so no surgery was needed. She was given the order for full weight bearing and sent back with a walker. The doctor, discharge planner and unit manager all agreed that she was not a candidate for a rehab facility due to her dementia. She got back to her ALF and within an hour fell twice. The ALF administrative staff was furious with me for letting her go back there. I wanted rehab, but I understood where they were coming from, and agreed that she would not be able to follow directions. Here are the issues.

1. When she fell, it was evening shift. No one seemed to know what to do, and I couldn't get any response as to who was in charge. It took 30 minutes for someone come and assess her. It was lucky my husband was there to go pick her up and put her in a chair (outside, in the cold). Went to ER and was admitted.

2. When the discharge planner called the ALF to give them report, not one administrative person was there-they were all at a meeting. When someone finally called DCP back, the ambulance was there to take her back. They were mad, but it was too late. I have no clue who was in charge during that time period.

3. Upon her return, she fell twice. The staff was furious with me for allowing her to go back. Maybe my attachment to the situation got in the way of my nursing judgment, but I felt I was doing the right thing. The DON demanded that I get 24/7 sitters. I did, because I I did not know what else to do, and I didn't want her to fall again.

4. I visited her one day and found her ted hose bunched up on her ankles and her knee immobilizer out of position and she was bending her knee. I got her hose and brace straight. I am suspecting that the aides there are not looking at this.

5. I called to speak to the DON about this the following day and one again, all of the administrative staff was out of the office and there was no one there to talk to about a clinical situation.

6. The day after, my mom had an issue with her telephone, and I was trying to get hold of someone in the facility because I needed to talk to her sitter. I called and called, and no one answered. Finally, the DON answered and I told her the situation. Her response to me was, "well, I was just on my way out the door to go home, and I heard the phone ringing so I answered it. After I asked why it took 3 tries for someone to answer the phone, she was mad. I also told brought up the knee immobilizer situation and asked her if she had looked at it recently. She said, "That's not my job, that's PT's job (who is there 2 days per week). I WAS LIVID!! Again I asked her who was in charge there, and she hung up on me. Talked to her sitter who told me she was back in her office and I asked her to tell her to please call me, but the DON never called back and I haven't spoken to her since.

7. My mom went to the ER Friday for combative behavior. Fortunately there was no medical reason, so they sent her back. She was given a prescription for Seroquel. I took the Seroquel to the medication aide and she called the DON. I was told the medication would have to wait until Monday, While I understand that the mediation aide can't just administer anything, if I hadn't been there, she would have gone 3 days without her prescription. I've been having to go over every night to give it to her. Again, who is in charge???? What if it was a more critical type of medication?

I am not used to this kind of behavior from any professional nurse, much less one who tells me "That's not my job". O.M.G

ALF nurses, what is your take on this? I'd really appreciate some feedback before I report the facility to the state. I want to have all my ducks in a row.

TIA!

[Sour Lemon]

She doesn't sound like the type of person who should be in assisted living ...not by a long shot.

[VivaLasViejas, ASN, RN]

I was a DON in assisted living for years, and I can tell you that is unprofessional behavior. The scope of practice in ALF is wide, you have a lot of autonomy in this setting, and never is it OK to say "that's not my job". It most certainly is. In fact, EVERYTHING is your job. You have to make sure the staff is doing things properly and that you're regularly assessing residents' capabilities as well as their physical and mental status. That DON is clearly uninterested in her residents and is letting the aides get by with doing the minimum.

I would advise you to kick this up the food chain to her supervisor, who is usually the Executive Director of the facility. She probably also reports to a corporate nurse consultant. I hope you can resolve this with them so you don't have to pull your mother out of the ALF.

[CharleeFoxtrot, BSN, RN]

She doesn't sound like the type of person who should be in assisted living ...not by a long shot.

I agree, sorry OP but your mother's level of care is apparently exceeding that facility's capabilities. Assisted living facilties are not meant for complex care issues. She might be better served by a facility that is 24.7 memory care. As for the DON being an (expletive deleted), I'd be looking for another place to keep my mother.

[Malia BSN, RN]

Thanks so much for your input! I'll get back with updates. :)

[Malia BSN, RN]

Her level of care is not the issue. I realize that she will no longer meet ALF requirements; rather memory care. I totally agree with this, and in fact I've spoken with the facility about this. But my concerns are with the DON who is rude, tells me "thats not my job", and hangs up on me when I ask who is in charge. This is very serious. My mom has NO health issues. She's medication assist only, otherwise, she's been independent in care. I'm thinking about the (fictitious) resident who has no close family, gets sent to the ER for, say, SOB. She's diagnosed with an exacerbation of CHF (normally controlled) and must take extra Lasix, HZTC, or whatever, and she can't can't get it for 3 days because the DON or designated clinical replacement is not available. That in itself is enough to send a resident back to the ER.

I'm sorry if I didn't make myself clear in my original post. My issue is the response to her needs and if this response is the norm in ALFs.

[Malia BSN, RN]

Her level of care is not the issue. I realize that she will no longer meet ALF requirements; rather memory care. I totally agree with this, and in fact I've spoken with the facility about this. But my concerns are with the DON who is rude, tells me "thats not my job", and hangs up on me when I ask who is in charge. This is very serious. My mom has NO health issues. She's medication assist only, otherwise, she's been independent in care. I'm thinking about the (fictitious) resident who has no close family, gets sent to the ER for, say, SOB. She's diagnosed with an exacerbation of CHF (normally controlled) and must take extra Lasix, HZTC, or whatever, and she can't can't get it for 3 days because the DON or designated clinical replacement is not available. That in itself is enough to send a resident back to the ER.

I'm sorry if I didn't make myself clear in my original post. My issue is the response to her needs and if this response is the norm in ALFs.

[AnnieOaklyRN, BSN, RN, EMT-P]

I have to be honest this is assisted living, it is not a nursing home, thus I don't think they are actually responsible for your mother's brace or other medical devices.

I think it sounds like your mother needs more of a nursing home rather than assisted living, as she sounds like she may be beyond the abilities of an assisted living facility. Assisted living facilities, to my knowledge, do not provide nursing care, and are intended for elderly people that still have a high level of independence, but who need help with meals and cleaning etc.

Annie

[VivaLasViejas, ASN, RN]

I have to be honest this is assisted living, it is not a nursing home, thus I don't think they are actually responsible for your mother's brace or other medical devices.

I think it sounds like your mother needs more of a nursing home rather than assisted living, as she sounds like she may be beyond the abilities of an assisted living facility. Assisted living facilities, to my knowledge, do not provide nursing care, and are intended for elderly people that still have a high level of independence, but who need help with meals and cleaning etc.

Annie

In this day and age, ALFs provide nursing care, almost as much as you'd see in a nursing home. When I first started, most of the residents were pretty self-sufficient and needed only basic ADL assistance (med management, bathing, dressing etc.). By the time my last ALF job ended, we were taking people with wounds, sliding-scale insulin, moderate dementia, total care including Q 2 hr turns, even tube feeders and two-person Hoyer lifts. We almost never required such residents to move to a higher level of care, because the senior living companies who run these facilities are all about profit and these folks pay a LOT of money to stay there. Where I worked, we moved only two residents out to nursing homes or memory care units in all the time I was there---one was a lady who kept running away, and the other a Parkinson's patient who was a three-person transfer (and that happened only after he wound up in the hospital after a serious fall).

This was all managed by one nurse and a group of unlicensed assistive personnel, few of whom had any formal training; in my state, they don't even have to be CNAs. I had to delegate insulin administration and other critical meds, wound care (although I involved home health agencies whenever I could), and tube feeding. And we paid these caregivers nine bucks an hour to oversee the health needs of vulnerable elderly and disabled people.

Looking back, I'm thankful I had good caregivers and med aides, but I wouldn't do it again.

[Malia BSN, RN]

In this day and age, ALFs provide nursing care, almost as much as you'd see in a nursing home. When I first started, most of the residents were pretty self-sufficient and needed only basic ADL assistance (med management, bathing, dressing etc.). By the time my last ALF job ended, we were taking people with wounds, sliding-scale insulin, moderate dementia, total care including Q 2 hr turns, even tube feeders and two-person Hoyer lifts. We almost never required such residents to move to a higher level of care, because the senior living companies who run these facilities are all about profit and these folks pay a LOT of money to stay there. Where I worked, we moved only two residents out to nursing homes or memory care units in all the time I was there---one was a lady who kept running away, and the other a Parkinson's patient who was a three-person transfer (and that happened only after he wound up in the hospital after a serious fall).

This was all managed by one nurse and a group of unlicensed assistive personnel, few of whom had any formal training; in my state, they don't even have to be CNAs. I had to delegate insulin administration and other critical meds, wound care (although I involved home health agencies whenever I could), and tube feeding. And we paid these caregivers nine bucks an hour to oversee the health needs of vulnerable elderly and disabled people.

Looking back, I'm thankful I had good caregivers and med aides, but I wouldn't do it again.

VivaLasViejas, thank you so much for your feedback! This has been a real eye-opener for me! I've done LTC myself (DON, Supervisor), but I have no experience with ALFs. After reading these comments and talking to coworkers, I am floored to find out that ALFs are basically useless at this point. Sure, everything's a party until someone gets hurt. I spent most of the day on the phone with the state ombudsman, the ALF administrator, and the DON. The ONLY thing now (at least at my mom's ALF) that the nurse does is set up meds. I'm sure that's an enormous task. She also coordinates home health skilled nursing and PT/OT/ST. I found out today that my mom had a skin tear (91, expected) but no one told me. Needless to say, not happy about that, but the DON said she is NOT ALLOWED to do wound care. So here I was, expecting her to check my mom's knee immobilizer and (really, can't) put a bandaid on a skin tear. No, ONLY home health can do these things.

Where are you located? I want to send my mom there! :)

No, really, I always thought I'd never put my mom in ALF/LTC, that I could handle her. But life doesn't always happen as we hope it will. This has been devastating to me that I can't just snap my fingers or twinkle my nose and let this all go away....

Thank you again.

[neuron]

Being that residents receive medication orders 24 hours a day (doesn't stop on a weekend), I would think that there is some protocol for this facility to administer the meds or be accountable. I would look up whether these DON's are allowed to do wound care or work the 'floor'. That seems suspect when one has a license.

[VivaLasViejas, ASN, RN]

Being that residents receive medication orders 24 hours a day (doesn't stop on a weekend), I would think that there is some protocol for this facility to administer the meds or be accountable. I would look up whether these DON's are allowed to do wound care or work the 'floor'. That seems suspect when one has a license.

Believe or it not, it's the corporate poohbahs who dictate what the nurse may and may not do. The company's policies may very well prohibit even basic nursing tasks such as CPR (and that's a whole 'nother post) and wound care. It's all about "liability". That's why I delegated as much to home health as possible. Not that I wasn't capable of overseeing these things, it was just that the company didn't want me providing the care myself.