Unsafe ?? Need opinions....

Long Term Care Columnist / Guide · Mar 6, 2011

Honestly? It's probably a combination of all of the above.

Unfortunately, you may be a bit unrealistic as to the degree of short-staffing; the ratios at your facility are actually fairly decent for LTC on an evening shift. Naturally, since you're new, it'll take some time to find your rhythm so you can complete your med pass correctly AND at the times specified......but you will. I've seen a single med tech pass to as many as 80 residents in an 8-hour shift---not that it got done strictly according to the rules, but the right meds were given to the right residents, and sometimes that's all we can ask for.

I'm also going to play devil's advocate for your med tech, although I do NOT approve of pre-pouring and would absolutely discipline her for doing the meds "from memory". That's wrong on so many levels that it boggles the mind. However.......med pass times are not set in stone.

With some exceptions (such as when pain meds are ordered by the resident's physician to be given q 6 hr, or Coumadin to be given in the late afternoon), administration times are determined by the facility for its convenience, not that of the staff or residents. Sometimes giving some of the 1600s and 2000s at the same time is the only way to get a pass done, but you have to go through the proper channels to change the times, as well as a good rationale. For example, there is no real reason to give metoprolol, four or five vitamins, bowel meds, and Coumadin at 1600, and then a single Colace at 2000. That's just silly, but oftentimes the folks making up the MAR don't think about that when they're scheduling the administration times.

On the other hand, if, say, OxyContin 80 mg PO BID is scheduled q 12 hrs, nobody should be giving that during the 1600 pass.......it's usually scheduled for 0800 and 2000 or thereabouts. Anyway, you get the idea.

All of that said, I happen to agree with you that your staffing situation is far from ideal, even though it IS legal, and it IS better than in some facilities. Before I went back to assisted living, I worked briefly in a SNF where I was the only nurse for 66 patients on noc shift, with 4 CNAs and NO med aide. Well, those skilled patients kept me running all night with PRN pain meds, and there were about 40 residents with 0600s, treatments, paperwork, chart checks, straight-cath UAs, blood draws, pharmacy deliveries etc. And of course, most falls would happen between 0500 and 0630, so there was THAT documentation to deal with.......it was hell, and I felt it so unsafe that I left within two months.

Long story short: LTC is one of the hardest, most thankless, and poorly-compensated areas of nursing there is. But if you have the heart for it, you'll find a way to make it work for you AND keep your sanity along with your license. Best of luck!

chelynn · Mar 6, 2011

I have to say you have it better than I do. I work 1800-0600 with 3 CNAa until 2200 and 2 after that. We have 45 residents. I have the med passes, treatments, tube feedings, TPN, among all the other stuff and then the charting, med orders, dr appointment paperwork and a ton of other stuff. Yes I hate my job, and tell myself I'm lucky to have one. I've been there 7 months and am looking for something else. I came there from the ER and let me tell you a bad day at the ER was nothing compared to what I have on my plate now. But to answer your question, yes it's legal, we always pass our state inspections. Is it dangerous? It can be. I think that is why I am so stressed because I work my butt off to make sure I do everything right.

dthfytr, ADN, LPN, RN, EMT-B, EMT-I · Mar 6, 2011

Long story short, if you don't feel you've been given adequate orientation, or that the job's just not for you, go with your feelings. If you try to push a bad situation and something goes wrong, the LTC facility isn't going to cover your asterisk. On the other hand, if you feel you can get in the rhythm of the place in short order, go for it. It's a decision only you can make (don't you hate that phrase?). Best wishes in whatever you choose.

vampiregirl, BSN, RN · Mar 6, 2011

We are set up a little different at the LTC where I work, but I ran into some of the same concerns as you have encountered when I first started. One thing I did was figure out who had meds that are time sensitive (every x hours or need to be administered before a meal) and made sure I passed those in the appropriate time frame. I can say I always use the MAR, but for those residents whose meds I'm familiar with I pull those out of the drawer and set them on the top of my cart in order. THEN I go down the MAR with the pulled meds and verify time, dose etc. With the meds in front of me, I don't lose my line of sight in the MAR. I also try to keep the boxes in the cart in the same order as the MAR, so on the first of the month it does take a little longer because most of the new orders from last month are now in alphabetical order. I just move those boxes to where they now are. It took me a good month on my own to even come close to passing my meds within the actual med pass times. It also get quicker now that I know exactly how each resident takes their meds. Also, talk to your manager to find out if some of the non-time sensitive meds can have their times officially changed. It does require a doctor order and the time required to make the changes, but with my manager's assistance we are slowly working to get the med pass under control. Good luck. I was totally overwhelmed at first, but now I am really starting to love working in LTC - most days:)

SirJohnny · Mar 6, 2011

j464335 & all:

- Most LTC facilities require the LPN to not only do the med pass, but also the treatments (ointments, wound dressings, foot soaks, etc.) in addition to the med pass. In addition, I am surprised you are not required to do the Medicare charting.

- Rule number one. "Nothing stops the med pass." If a patient falls and you didn't see it ... get the charge nurse, and let her handle it from there. A patient needs fed or taken to the restroom ... hit the call bell light and let the CNA deal with it. Angry families ... let the RN or DON deal with it.

- Note that most residents are in bed by 7pm. Their time cycles are dictated by the sun ... not by the clock. This is why changes from daylight savings to standard time (and back) create so much havoc the first week or two.

- That being said. It's fine to give your 9pm medications with the 6pm med pass, with the exception of insulin and any heart medications. Essentially, you combine your 5pm meds with your 9pm meds.

- Before giving me hell ... think about this. Most of these folks are demented and sleeping by 7 or 8pm. Now you want to spend 5 to 10 minutes trying to wake them up (most don't wake up). Then sit them up in bed, and then run the risk of aspiration on a tired, demented person while you are 2 hours behind on the med pass. So, just give the 9pm meds with the 5pm meds (except for insulin).

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- Rule #2: Always look at the MAR when pulling meds. If the DON or anyone else gives you crap about this, then immediately stop the med pass. Call the RN and tell her that it's an unsafe environment and you are informing him/her of this. Immediately, take your 30 minute break to let things cool off. Come back and finish the med pass (using the MAR). Don't come in the next day. Instead, get yourself another job. NEVER, EVER give meds without looking the MAR (medication administration record) and comparing to name bands.

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- Rule #3: You usually don't get a lunch break on the med pass. I have no problems with ordering myself a dinner tray, or scarfing food / drink from the kitchenettes. Believe me, you will get used to eating and passing pills at the same time.

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- If you think passing meds at the same facility is tough ... try being an agency nurse. We get called at the last minute to many facilities (LTC). I currently work agency at about 30 different facilities ... any one of which can call me at the last minute for a shift. It's how the agency game is played.

Hence, the reason I insist on looking at the MARs and comparing to ID bands when doing the med pass.

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- Hang in there ... it's tough out there, but doable.

- Good luck.

SirJohnny

NamasteNurse, BSN, RN · Mar 6, 2011

Sir Johnny is honest. I wouldn't want to admit to all that, but it does happen in LTC. You actually have pretty good staffing ratios. I do my whole floor 43 alone. 3-4 aides. But I am meds, charge, treatments and charting and everything else, ordering, pharmacy, labs, doctors, families, paperwork. god forbid someone falls or you need a med from the supervisor. You probably do need more orientation but if they arent offering it, just go in and do your job for 8 hours then go home. Its LTC.

Mulan · Mar 6, 2011

They actually wear name bands?

I've heard of no name bands, and not being able to tell who anyone was, relying on other staff to ID the person, or having to rely on a picture (lol all look alike).

caliotter3 · Mar 6, 2011

Long story short, if you don't feel you've been given adequate orientation, or that the job's just not for you, go with your feelings. If you try to push a bad situation and something goes wrong, the LTC facility isn't going to cover your asterisk. On the other hand, if you feel you can get in the rhythm of the place in short order, go for it. It's a decision only you can make (don't you hate that phrase?). Best wishes in whatever you choose.

I say this. It can only be improved by having another person to pass meds. They should have hired you for full time.

Angie O'Plasty · Apr 24, 2011

They actually wear name bands?
I've heard of no name bands, and not being able to tell who anyone was, relying on other staff to ID the person, or having to rely on a picture (lol all look alike).

Having worked agency in LTC facilities, I can vouch for this!! Extremely unsafe, especially on a unit where the residents are not alert and oriented (at least for residents who are A&O you can ASK them their name). Unfortunately this situation is more the rule than the exception from what I have seen. I made a med error once because of this issue...I was on a dementia floor, residents didn't have name bands on, and there were two residents with the same first name who were roommates (not a good idea). When I asked a staff member to point out "Dorothy T." in the dining room, they pointed to a resident, I got the meds, and returned to give them. I asked another staff member "this is Dorothy T., right?" and they said yes, or at least that is what I heard. I gave the meds, then asked the other nurse to point out "Dorothy S.", the roommate--and he pointed out the lady I had just given "Dorothy T."'s pills to!!! Needless to say, I had a major case of tachycardia, assessed the patient, and notified the NP who happened to be on the floor at the time. Fortunately most of the meds were things like vitamins, aspirin and Colace (and nothing on her list of allergies), but there was also a cardiac med in there that thankfully this resident was also on, just at a different time of day. We kept an eye on her heart rate and BP and she had no adverse effects, but the whole thing scared the heck out of me and made me that much more stressed out when going onto an unfamiliar unit and passing meds.