Time management, Patient ratios and Moral turpitude in Rehab/LTC

NotFlo · May 28, 2017

Moral turpitude is a great way to describe the staffing in LTC/rehab. Unfortunately, 1 nurse to 28-30 patients is absolutely the norm anywhere I have ever worked at least on a LTC wing. In straight rehab (with almost no LTC people mixed in and high acuity, lots of wounds/would vacs, IVs, TPN, traches etc) I have seen 1 to 15 and that feels like a horrible nightmare sometimes. It doesn't matter how impossible the 1 to 30 ratio can be, that seems to be the industry standard and they are never going to change it. I doubt you will find any where that has less of a ratio than that. The difference is some facilities do provide more support that make it more manageable...more CNAs, help with admissions (I already feel like I'm doing 12 hrs of work in an 8 hr day then I find out I'm getting an admission...ugh!)

CoffeeRTC, BSN, RN · May 31, 2017

I think that is a great breakdown of the shift work. I think the ratio really depends on the acuity of the residents. If they are more LTC and less skilled, then you might have more meds, but less assessments. The med pass is what needs streamlined. There are way too many meds on stable LTC residents.

CapeCodMermaid, RN · Jun 1, 2017

Oh puhleeeze. Lack of a moral compass? Get over yourself. I've been in the business for years and have seen all the changes good and bad. The staffing ratios are not good but it's due to the reimbursement structure. Most DONs have no say in the staffing patterns. I stay because I care about the staff and the residents. Better someone like me who cares than someone who just gets a pay check. SO how dare you say DONs don't have a moral compass.

cyc0sys · Jun 7, 2017

The staffing ratios are not good but it's due to the reimbursement structure.

Medicaid reimbursement were I worked was 480.00 per patient per day, allocated specifically to nursing care services only. You could hire 3 nurses at 16.50, current starting rate here, and provide 24hr care for one patient and still have money left over.

Most DONs have no say in the staffing patterns. I stay because I care about the staff and the residents. Better someone like me who cares than someone who just gets a pay check.

They can vote with their feet. I'm not sure what the difference is between 'caring' and a pay check, the math does not lie. Any DON knows unsafe staffing numbers are directly related to sub-par care and burnt out staffing. As one poster pointed out, the numbers may differ a bit based on acuity but at some point your still playing life boat politics with care and there aren't enough nurses to go around.

As long as DONs maintain the status quo, they become part of the problem not the solution. Any type of martyrdom that may be garnered is directly undermined by those same efforts because people aren't going to stop growing old or sick yet the staffing numbers remain unchanged. Who really bares the shame then?

Professionally, I would never knowingly place my patients, my staff, and myself in an unwinnable situation whether it was for personal gain or because I cared.

CapeCodMermaid, RN · Jun 8, 2017

I don't know where you work but MassHealth does not reimburse at that high a rate. We lose money on most long term residents.

cyc0sys · Jun 13, 2017

That's possible but not very likely if you work at a For-Profit facility. Something that might appear as a loss will most likely be written off by the business office and offset as the cost of doing business in order to maintain Medicaid requirements e.g. a certain number of medicaid LTC patients per beds in the facility.

This routinely happens in my facility because the rehab side generates a much greater return and offsets the cost of an LTC patient. So it's a calculated 'loss'. Not to mention the fact that For-profit facilities are notorious for over billing as represented by a 30% of claims denial by way of comparisons to the 15% a Non-profit facility generates.

You are correct that MassHealth typically reimburses 70% of the cost, like most state Medicaid programs. But there are many other factors that determine reimbursement rates, most of which are very individualized right down to the building construction and age.