The ridiculousness of LTC/SNF

[YUKONrn]

Oh where to begin. Anybody else running to save their sanity and nursing license or is it just me? I have been an RN since 2007 so I'm a very seasoned nurse. For the first 9 years of my career I worked strictly in hospitals. I worked on just about every unit imaginable with the exception of OB, peds, and NICU. Over the last 3 years I transitioned to LTC facilities thinking that having a routine and the same patients every shift would be less stressful. And initially it was. The first LTC I worked at I liked until a CNA who had no business becoming a CMA (she was a meth addict) was put through CMA school by this facility and became a CMA on my hall. Over a period of months myself and other nurses noticed that she was getting done with a med pass that took a seasoned nurse 2 hours to complete in 30 minutes. Especially as a brand new CMA, something was amiss.

Then residents who were alert and oriented were saying they weren't getting their pain medications. The CMA would always insist that the pain meds were given. Well one weekend when a nuse was working the med cart and was swapping out the sharps containers and noticed that it wasn't full of used needles, it was chock full of pills. We figured out how she was getting through the med pass so quickly, she was popping them and putting them in the sharps container, and she would pocket the narcotics. We notified the DON, but not a single thing was done. And she actually got smart and would give the very few residents who were alert and oriented all of their meds, but she continued to pop the meds of the residents with dementia but instead of putting them in the sharps container, she would throw them in the trash and then empty the trash well before shift change thinking nobody would notice, but we did notice and reported her to the DON, once again nothing was done.

One day one of my residents with a history of epilepsy had a grand Mal seizure in the dining hall. I notified the doctor, the doctor asked how much Dilantin he was on, so I told him, and the doctor stated "wow he is on the max dose of dilantin. Get a Stat dilantin level." Guess what his dilantin level was? Zero. He wasn't getting his dilantin (real shocker, nobody was getting their meds). I felt like my license was at risk and the DON refused to take action against the CMA so I resigned.

I got a job at another 172 bed LTC/SNF. They told me that the SNF portion is 20 beds, so they have 2 nurses on that hall, each nurse gets 10 skilled residents and then in addition you split a LTC hall and took 10 LTC residents. So essentially you have 20 residents which is not too bad for the 3-11 shift. In July this independently owned LTC/SNF was bought out by a large corporation who like all corporations are focused on the profits, we were told that we would be getting a lot more skilled residents and that they were actually turning one of the LTC halls into another SNF hall. They also told us we would be getting higher acuity residents with TPN, wound vacs, pressure ulcers, bipaps, etc. What they didn't tell us was that they were taking one of the nurses away. So now you have 1 nurse for 20 high acuity skilled patients and you also have 20 LTC residents. The nurse that was working day shift when they made the change said "this is not safe" and quit. They brought a nurse from one of the other LTC halls to work and she made it about 2 months and then quit. They asked me if I would go to 7-3 for a $5 an hour pay raise and like an idiot I agreed in September. And in came the higher acuity patients which 90% of them I can tell you belong at an LTACH not a SNF.

Here comes the good part. We work 8 hour shifts. On Monday the NP comes and you have to round with her on EVERY skilled resident and give her a rundown. That alone knocks an hour off your shift. If she gives you 75 orders, you have to put the orders in the computer and fax them to pharmacy, etc. Kiss another hour off your shift. Then you have to go to standup, and seeing as there are 172 residents in the building and every resident has to be reported on, that knocks another hour off your shift.

So you get to start off the work week trying to do the job of 2 nurses and 12 hours worth of work in 5 hours.

20 skilled residents means 20 complete sets of vital signs, 20 had to toe assessments which you have to document in the computer, 10 residents with fsbs who get ss insulin, we have a wound care nurse but she doesn't do any of the wound care she just rounds with the wound care doctors once a week on Wednesdays and they rip off everybody's dressing and take measurements (but don't replace the dressing). In fact you don't even know that the dressing is off until PT or OT says "Hey we just came to get Ms.Jones for therapy but her dressing was removed and she's lying on her side." You walk into the room and sure enough there the resident is with their a** in the air but because PT has a schedule too, you have to drop what you'really doing and do wound care. You have patients crashing left and right, one day I sent 3 skilled residents out and all were admitted to ICU. Wound vacs galore, TPN galore.

The day I told myself "enough is enough" I had 20 SNF residents and 20 LTC residents. Of the 20 skilled residents, 6 of them were hoyer lifts, 8 of them were 2 person transfers, 2 were getting TPN via PICC line and they needed lab work drawn and the results faxed to pharmacy, both of their PICC line dressings were due to be changed. One residents lab work came back and his creatinine was 4.62 (no history of kidney problems so he got sent out), I had 2 wound vacs dressings that needed to be changed, 3 people with stage 3 or higher decubs that needed their wet to dry dressings replaced, 10 on fsbs with ss insulin, 3 peg tube 2 of which were continuous, the other one was bolu feeding, 6 people on duonebs and it is corporate policy that you cannot leave the resident unattended while the duoneb is going, 3 of my LTC residents had fallen and were on neuro checks 2 of my LTC residents had MD appointments, my TPN arrived and I had nowhere to put it because our refrigerator was full of antibiotics. As I'm talking to the ADON about where to put the TPN, 2 admits roll through the door at the same time and my CMA shouted to me "Hey their rooms aren't even ready yet!" I yelled back "WTF do you want me to do about it?" And to top it all off neither our printer nor our fax machine worked at all that week so you had to go clear across the building every single time you needed to print or fax anything which you know is pretty frequently. For the last month my 8 hour days have become 11 hour days. I had a nervous breakdown and self terminated that weekend. Right now I'm on a mental health vacation. WTF is Healthcare coming to?

[amoLucia]

I am really sorry that you've had to experience all that. There really isn't anything I can say except to wish you all the best.

[ThePrincessBride, MSN, RN, NP]

I got stressful just reading your post.

Unfortunately this isn't uncommon and one of the reasons I won't ever work step foot in ltc/snf again.

Start looking for a new job...STAT.

[YUKONrn]

I got stressful just reading your post.

Unfortunately this isn't uncommon and one of the reasons I won't ever work step foot in ltc/snf again.

Start looking for a new job...STAT.

LOL! At least it isn't just me who thinks their expectations are absurd. I actually start at an LTACH in March. If I'm going to take care of LTACH patients bet your butt I'm going to do it in a facility that's equipped and staffed for it! I had one skilled resident who went to the ER with AMS, they diagnosed him with a UTI and sent him back with a script for omnicef. The ER called 2 days later and the C&S grew ESBL that was resistant to omnicef. But it was susceptible to amikacin. So the doc wanted to start him on IM amikacin BID x 7 days. Guess how long it took our pharmacy to send the amikacin? 3 days! I'm not even kidding you! By that time he was septic...I have to laugh because if I don't I'll cry.

[Here.I.Stand, BSN, RN]

LOL! At least it isn't just me who thinks their expectations are absurd. I actually start at an LTACH in March. If I'm going to take care of LTACH patients bet your butt I'm going to do it in a facility that's equipped and staffed for it!

Fair warning... I have worked in LTACH and it was by far my most stressful nursing job. You cite wound vacs and TPN as examples of things that should be LTAC vs LTC, but in my experience those things were not enough to justify LTAC. I mean a person *could* receive TPN or wound care at home with a home health nurse.

A bit of what did justify a bed in the LTACH where I worked: mechanical ventilation, telemetry, at-minimum daily labs, heparin/insulin drips, blood administration, severe burns (discharged from the burn unit to LTACH), hemodynamic instability, sepsis.......

A lot of our pts were admitted directly from traditional ICUs. They were too high acuity for med-surg.

[Crush]

Oh my gosh, that sounds so stressful. I have not worked in LTC in a while but that is just insane.

[Eris Discordia BSN, RN]

OP,

That makes my former trauma level 1 and transplant PICU and peds CVICU with ECMO experiences seem like a serene walk thru a floral meadow during a butterfly release on a balmy, spring day.

Dang.

[smf0903]

I think I got an ulcer reading this post. My gosh, that is crazy!

[YUKONrn]

Sorry! It's 100% true SMH. No the ones who require an LTACH but we take anyways because all of the LTACH's are full usually crash within 24 hours of admission and end up getting sent back out because we don't have an in house CT, X-ray, RT, doctor, or even bipap machine available if their issues are respiratory in nature. And our o2 concentrators only go up to 5L so god forbid somebody needs to be on a nonrebreather until EMS arrives. If an x-ray is ordered stat, the x-ray company we use has up to 4 hours to obtain it, and then it takes another 2 hours to get the report. I sent 3 residents out one day and all were admitted to ICU, all had been at the facility less than 72 hours. So essentially that day I took care of 3 ICU patients, 17 skilled patients, and 20 LTC patients.

[YUKONrn]

OP,

That makes my former trauma level 1 and transplant PICU and peds CVICU with ECMO experiences seem like a serene walk thru a floral meadow during a butterfly release on a balmy, spring day.

Dang.

ROFLMAO if I don't laugh I'll cry. Makes my days of having 2 Balloon pumps and a DKA on an insulin drip with hourly blood sugars seem like ice cream, rainbows, and unicorn farts.

[YUKONrn]

He'll at least in the ER we could B52 them and tie them to the gurney if need be. The state just made it illegal to use chair alarms and bed alarms. People are falling and cracking their heads open so the families threaten to sue, and you aren't allowed to say "we're understaffed", that's a big no-no. Zyprexa? Can't use it in LTC, it's considered a chemical restraint. Haldol? Can't use it because that's considered a restraint. Siderails on the bed are considered a restraint. All you can do is put the bed in a low position, lay a mat next to it and hope for the best. But they get up and fall and Crack their heads open so you have to notify the dr, notify the family, call 911 so they can go to ER for staples and a CT. When they return you have to initiate neuro checks, and pray that they don't fall again but they do. And they hit their head again, but maybe they didn't split it open so they don't need to go to the ER but you have to notify the dr, notify the family, fill out an incident report, and start neuro checks all over again. Fun times..

[YUKONrn]

And unfortunately I'm only an ADN, and I live in a big metro area, so you do need a BSN to land a hospital job, even though I worked critical care for 9 years. Hell I worked critical care with nurses who only had a nursing diploma back in the mid-2000's. RN diploma programs don't even exist anymore.