WHAT were they thinking at that Nursing Home???

[JDougRN, BSN, RN]

OK- just let me say up front, this is NOT a flame of LTC nurses. I want your opinion about something.I'm an ED nurse who has worked in your shoes as well, and I understand how hard your job is, and how much good you do on a daily basis. There is a certain amount of discourd at times, between LTC and Hospital nurses- I've heard (NEVER SAID) that people who can't "handle" the pressure of working in a Hospital have to go to a LTC because they don't have the necessary smarts, skills, coping mechanism, ect. to "hack" it in the real world.(I disagree with that statement). I've precepted students who have actually said things like this, so I'm not sure exactly where it comes from? I also understand that our priorities are different from LTC nurses, based on what we do for our patients. Something happened the other day involving a LTC pt. that left me flabbergasted!

I got a 62 yo male with acute/rapidly advancing dementia. His wife of 2 yrs is at the bedside. He is aggressive, aggitated. According to the wife, he was "normal" 2 yrs ago, but the dememtia is rapidly getting worse. So much for the man she married (sigh...) So this man was sent to me from his LTC facility for "UTI". He had had a Foley cath placed 2 weeks ago d/t inability to void/prostate issues, and is supposed to be waiting for a Urology consult to be arranged by the LTC faclitiy. The report I got was that the man had an indwelling Foley cath, foul smelling urine, temps, ect. OK- good pick up by the LTC place, right?

I undress this man, and find no leg bad- he's wearing sweat pants, with underwear, and 2 briefs on underneath that. THE FOLEY IS STILL IN...OPEN...without any type of bag/collection device, ect. draining right into the adult diaper. It's not clamped in any way- What the &%$#!!!!! I question the wife- according to her, the staff told her the leg bag/drainage bag "aggitated" the patient, so they just took it off. No way ANYBODY with a nursing license would do something that stupid, right? So I called the NH, spoke with the RN Supervisor. SHE KNEW about the situation- informed me that the NP had ordered it to be dealt with that way. I basically called her a liar (professionally, of course)- She said she'd fax me the written orders. She did, but all it said was that the man should be placed on a clamping schedule- So I called her back-told her that a clamping schedule would be appropriate, but was NOT the same thing as leaving Foley cath open. HELLO???? SHe then proceeded to backpeddle, saying that it was probably clamped, but that the man must have taken the clamp off. 1. There was no way the man could get to it with all of those layers, 2. the man's wife told me that they were lying, and that she had questioned it multiple times. How could ANY nurse think that was a good idea? I understand that the NH is their home, and things are done a bit differently than in a hospital, but seriously? Leaving a Foley open like that..then wondering why he got a UTI....I'm still amazed that anybody, let alone several nurses, could forget their training and think that would be appropriate? What do you guys think?

[Whispera, MSN, RN]

aaack!

[sweetnurse63, BSN, RN]

First of all, let me say that it was unacceptable for the patient to be transferred from the nursing home in that state which was a perfect set up for urinary tract infection. Now I am a RN who left the hospital to return to Long Term Care and I have seen patients return from the hospital with bedsores that they did not have before and other issues. So, it is so unfair to compare hospital and long term care nurses. It takes great critical thinking skills and good judgement and prioritization no matter where you work as a nurse. Emergencies can happen anytime or any place. Short staffing is a problem in the hospital and nursing homes which directly affects patient care and some staff need to be re=educated in the prevention or to decrease the number of urinary tract infections. I have told some of my CNAs to not put on double pampers or double pads due to the increase in moisture which can cause skin breakdown and infection. So, it is about educating and not about hospital vs nursing home nurses. I could say a lot more, but i will stop right here.:)

[roser13, ASN, RN]

First of all, let me say that it was unacceptable for the patient to be transferred from the nursing home in that state which was a perfect set up for urinary tract infection. Now I am a RN who left the hospital to return to Long Term Care and I have seen patients return from the hospital with bedsores that they did not have before and other issues. So, it is so unfair to compare hospital and long term care nurses. It takes great critical thinking skills and good judgement and prioritization no matter where you work as a nurse. Emergencies can happen anytime or any place. Short staffing is a problem in the hospital and nursing homes which directly affects patient care and some staff need to be re=educated in the prevention or to decrease the number of urinary tract infections. I have told some of my CNAs to not put on double pampers or double pads due to the increase in moisture which can cause skin breakdown and infection. So, it is about educating and not about hospital vs nursing home nurses. I could say a lot more, but i will stop right here.:)

OP took great care to specifically point out that this was not an us vs. them argument. She simply would like some understanding as to what could possibly be a rationale for the patient condition that she observed.

[TheCommuter, BSN, RN]

I agree that leaving an indwelling urinary catheter open without any collection bag is sloppy nursing and was probably the number one contributing factor to the development of the resident's UTI.

Although I do not agree with removing the collection bag and leaving the Foley open, I can walk a mile in the other person's shoes and conjecture why a handful of LTC staff out there would do it. Some demented residents are alarmed by the sight of the collection bag. After a while, they become agitated to the point where they are pulling on the Foley. I have had residents do some serious damage by yanking the Foley out with the 30cc bulb intact (covered in blood, of course).

Walk a mile in the other person's shoes. The LTC nurse, in all likelihood, had 30+ residents and did not have time to hover over one singe agitated resident. Therefore, he/she might have removed the very thing that was making the resident agitated: the collection bag.

Sloppy care is inexcusable. However, I am simply opening the window to a certain mindset that can prevail. Good luck to you, and I hope your patient is okay.

[JDougRN, BSN, RN]

It takes great critical thinking skills and good judgement and prioritization no matter where you work as a nurse. Emergencies can happen anytime or any place. Short staffing is a problem in the hospital and nursing homes which directly affects patient care and some staff need to be re=educated in the prevention or to decrease the number of urinary tract infections. So, it is about educating and not about hospital vs nursing home nurses.:)

I totally agree- Again, I wanted to make sure everyone knew I'm not trying to bash LTC nurses- I have a great respect for all they do. I was just wondering how a concept as basic and simple as Foley cath care could be ignored. HOW could that have gone through several shifts of nurses without somebody stopping and saying "Wait a minute here...." I was more aghast that the Nursing Supervisor knew about the practice, and not only did nothing to fix it, just went along with what they were doing! Then when I questioned her about it, she back-peddled and lied, saying the patient must have taken the clamp off. She really had no idea that the entire practice was totally against best practice. How does that happen?

And I have worked in LTC myself, so this isn't a case of me not knowing what it is like to have 40+ residents to care for.

[NurseLoveJoy88, ASN, RN]

I totally agree- Again, I wanted to make sure everyone knew I'm not trying to bash LTC nurses- I have a great respect for all they do. I was just wondering how a concept as basic and simple as Foley cath care could be ignored. HOW could that have gone through several shifts of nurses without somebody stopping and saying "Wait a minute here...." I was more aghast that the Nursing Supervisor knew about the practice, and not only did nothing to fix it, just went along with what they were doing! Then when I questioned her about it, she back-peddled and lied, saying the patient must have taken the clamp off. She really had no idea that the entire practice was totally against best practice. How does that happen?

And I have worked in LTC myself, so this isn't a case of me not knowing what it is like to have 40+ residents to care for.

I guess when some people see a post that starts off like like" This is not to bash x,y,z" Or "No offense" Automatically people are going to look for the very thing you say you are not trying to do.

Anyway, I digress. I agree that the whole situation seems messed up. Not sure why the NM is lying.

[nrsjo60]

Well I agree with both of you. Good judgement, patient safety, an d do no harm is always first. I dont think we help each other if we bully the nurses at the SNF's. Nursing care at the snf is totally different than at an acute care hospital , esp. in an ED. Not to say they don't follow infection control issues, but the plan of care is not the same in sub acute care or convalecent care. Skin care, keeping weight on, keeping patients moving and propelling, monitoring psychotropic meds, documenting..its hard work....this nurse probably should have connected the foley to a bag, but some reason she felt leaving open to a diaper might have made sense to her. Instead of bully her, maybe coaching her would have been more prudent.

I have worked in Er, ICU, eduation, LTC.. every envirorment has its own stressful envirorment and difficult situations makes pts more to the next level of care. Coach, manage, take on the challange as she is handing off to you and just take care of the patient......the other nurse is right...Hospital nurses tie pts down, wont let them up to walk, dont walk them, rely on PT to do all the ambulation, dont feed there patients, and these patients go back to the snf in a mess...I have witnessed it many times,...LTC nurses are caring and the know there patients well so give them the benefit of the doubt and stop being such a princess and try teaching or using your skills in a positive way and not a punitive way:nurse:

[babyNP., APRN]

Oh my goodness I'm so glad I don't do adults. I would probably quit nursing.

I hope your patient does okay too...that poor wife.

[JDougRN, BSN, RN]

.LTC nurses are caring and the know there patients well so give them the benefit of the doubt and stop being such a princess and try teaching or using your skills in a positive way and not a punitive way:nurse:

I take great offense to that statement. By trying to educate the staff at the NH, or being SHOCKED that nurses would harm a patient in this way, I'm being a princess? Comments like yours are what lead to the friction between different places like ED and LTC. This is a BASIC infection control issue, and the problem I had was that nobody seemed to think it was a big deal. Even the wife, who doesn't have any medical training, figured out this was a bad idea and questioned the staff about it. No matter what the venue is, hospital or NH, some things, like BASIC INFECTION CONTROL don't change. Would you have passed your clinical rotation in school if you did that to a patient? Absolutley not. If one of my students did that, I'd have HUGE concerns about their standards of practice.

[JenniferSews]

I think if you had not titled this with "at that nursing home" you would probably not be getting this response. Because regardless of the setting, no nurse should ever do something like leave a foley open, right? But you put nursing home in the title like that is half of the problem.

[morte, LPN, LVN]

if the collection bag is causing agitation (I don't think I have ever seen that be an issue) it needs to be disguised or out of the patient's line of sight. If that is not possible, and the patient can not do without the foley, how about plugging it and draining q6-8 hours?