What do you consider a heavy patient assignment?

CoffeeRTC, BSN, RN · Sep 30, 2016

Well, that just about covers my facility. Our acuity varies. The CHF patient with fluids and hypocalemia...that would have put me over the top due to the constant need to monitor. This patient should have been sent to the hospital for closer monitoring. Sad, but this it what a good bit of LTCs are looking like.

Leonardsmom,LPN · Sep 30, 2016

From what I have been seeing where I work now as a nurse compared to other places that I have worked at when I was a CNA, is that the people who are being admitted are sicker, more unstable than I have seen in the past. Where I work we are a 100 bed facility with half of our building being long term and the other half short term rehab. On all of our units now we have trach patients, currently 5 in the building. Out of those 5 only 2 are stable. One of the trach patients that I did the admission on about two week ago requires extensive care, is a quadriplegic with a stage 4 decubitus sacral ulcer that has a wound vac, and is receiving antibiotic therapy for MRSA. They were placed on a unit where the nurse working that hall usually has 20-25 patients depending if all the beds are full. The rest of the patient load includes another trach, several others with CHF, COPD, a young stroke patient that has had about half a dozen falls and so on. This is suppose to be the area that is considered long term, with more stable patients, unfortunately is not the current reality.

We we have had agency nurses who have come in, that don't return saying that it is the worse experience they have ever had. We have a lot of patients that in reality need to be in the hospital still, at least in an LTACH floor where the nurse to patient ratio is lower and closer monitoring can be done.

The problem stems from a few different areas, I believe. The first is the insurance companies that we only pay for a person to stay in a hospital for so long, many patients I think are being moved out of the hospital before they should because the insurance company will only give a person so much time. Another issue is that at least where I am at, is that the building had not been making money for so long (changes in company running the building, and changes in management) they lower the standards of what they will take into the building, allowing sicker patients to come in. The companies running these nursing facilities continue to staff the way you would staff a long term care unit, the problem is that we are no longer representing what LTC facilities use to look like, and we are starting to look more and more like what you would see in a med-surg floor or an LTACH floor, however with less staff and higher nurse to patient ratios.

NurseSpeedy, ADN, LPN, RN · Sep 30, 2016

The craziness of long term care is why I went back to finish my RN. Nursing is busy everywhere but LTC seemed to define the word insanity for me. I worked in a hospital setting years ago and after a short stent in LTC I had a strong will to go back to where I came from. For those who can thrive in that environment, you are some super nurses!

Double Dunker · Sep 30, 2016

Oh my. Just your rehab patients on my medsurg floor would be considered heavy. Hats off to all you LTC nurses. You amaze me.

Buyer beware, BSN · Oct 1, 2016

Last year I returned to LTC PRN after 5 years of working in clinics,, we are a billed as a low acuity LTC w/ 8 beds dedicated to rehab patients. When I first started working, the rehab patients were stable, mainly hip fractures needing PT/OT, and stroke patients that were needing a little extra time before they went home.
The types of rehab patients they have been taken in lately are more sick than they ever been. Because we are supposed to be low acuity, we don't really have the capability in terms of time to take on more critical patients since all 25 of my patients are separated into 3 different halls.
My last shift was a double, I had 17 LTC patients, 6 rehab patients, and two empty beds. My 6 rehab patients consisted of a PICC line w/ ATB for sepsis (he was pretty stable though), patient w/ multiple wounds(one on the coccyx so constantly needed changed because he had many BM in a shift) and patient had c-diff. 3rd patient was pretty much self reliable, 4th was hip fracture w/ low hemoglobin who I was constantly monitoring due to pain and possibility of hemorrhage (she was like 2 days post op and hemoglobin was trending down), 5th patient walkie/talkie but very agitated with no orders for any type of anti anxiety due to family request, and my 6th patient on IV fluids, with hypokalemia/CHF who I was also constantly monitoring to make sure she wasn't filling up with fluid plus I was very concerned about the fluids + already hypokalemic situation so I was in contact w/ on call often. Plus my 17 other LTC patients. I never took a break (which lets get real, who does in LTC) nor never sat down besides to chart for 16 hours.
My boss happened to come in for the other side because no one over was scheduled to work. I ended up calling her at 2100 because one of my aides called to inform me one of my LTC patients was bleeding from the rectum which is the first time this has happened for this patient. I couldn't leave my rehab patient because she was starting to fill up with fluid, I stopped infusion per MD, and was in the middle of getting all of the other orders for her together when this happened.
My boss acted like I was incompetent. Now, I am no LTC expert so I am wondering if from your all's perspective if I may need to change my time management habits or if this is an actual heavy assignment. I am due to graduate with my RN in April and I want to make sure if I am not being efficient enough with my LTC patients to complete all of my tasks that I start figuring out why that's happening before I work in a hospital and have more critical patients than what I have now....

"My boss acted as if I was incompetent."

Your Answer: "Feel free to pitch-in boss."

cmbauer42 · Oct 1, 2016

This sounds pretty standard for LTC right now, and yes it is a heavy assignment. I got out of LTC a few years ago after more than 20 very satisfying years. The acuity kept going up and up without any changes in staffing and I just found it impossible to give the quality of care I believe in.

nursejoy1, ASN, RN · Oct 1, 2016

I work at two separate facilities. One has a nurse:resident ratio of 1:24 or 1:28 on day shift, except rehab which is max 1:18. Night shift is max 1:34. The other facility routinely has one nurse for up to 60 residents on night shift and they wonder why they have such high turnover. They have asked me to work nights at the second facility and I absolutely refused. I told them they are putting their nurses' license and their residents' lives on the line.

AlwaysLearning247, BSN · Oct 1, 2016

I work med/surg telemetry and usually start with 4 and discharge one and admit one or two. It really depends on the acuity of patients. I've had assignments where someone is fresh post op, vomitting blood, and tachy, while another patient is withdrawing from ETOH very badly and another patient who is so sick and we gotta wait for a CCU bed or med flight. Those days can be very stressful. I've had up to 5 on med surg/tele and been fine and I've also had two and been super stressed, so it really depends.

purplegal · Oct 2, 2016

Sounds like a typical night at my place.

But yes, it is a heavy assignment.

WinterLilac · Oct 2, 2016

Coming from nursing in the community, the trend is to keep them at home for as long as possible. When they eventually enter an LTC, their needs are far higher.

To answer your question, perhaps book a time to sit with your boss for some professional development. Bring up that shift and what happened and ask her for some constructive feedback. Don't be defensive, be open and accomodating - your boss will see straight away if you're genuinely wanting advice or want to defend yourself.

Perhaps you might be able to do a buddy shift with another RN to see how they manage.

Or you might be surprised to hear your boss agrees it was a heavy load and changes might be made.

Either way, keep communication open is my advice.

Long Term Care Columnist / Guide · Oct 2, 2016

When I worked SNF, I had up to 30 patients (on day shift!) with a med/treatment nurse and four or five aides. That was 15 full assessments I had to do and document (swing shift did the rest), doctors' orders to be processed, wound rounds, fingersticks and insulin, phone calls, labs, and dealing with families. And don't forget admissions!

OP, your assignment is also too heavy, especially with the type of acute patients your facility is accepting. I can't imagine how you do it, although when I look back on my days in SNF I wonder how I did it. That's just LTC for you!