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?
That is simply tragic. I have worked both LTC and Hospital. My LTC nursing ended almost as quickly as it started for reasons like the OP found. Unfortunately you get some shoddy nurses working LTC. Its not to say that all, or even most, LTC nurses are like this, but all it takes is one or three really off beat nurses to ruin the bunch. Usually an enabling charge to go with it.
I worked at a LTC facility every other weekend to supplement my oncology job while I was going through school. They called me the "clean up" crew because I would spend most of my weekends redoing spotty things the other nurses had done the 2 weeks prior with incorrectly done orders, wound tx ect.
One day I got on shift and got report from one of the "not so on top of it" nurses that worked at this facility. Herself and 3 other of the same type of nurses were responsible for this wing through the week. I got the typical, "Everything is just great, the world is sunshine, now let me get outta here" kind of reports. Needless to say I found a patient in a pool of her own blood that had a GAPING leg wound that looked like some animal had taken a chunk out of her leg. The blood was dry.
The CNAs had put her back into bed and the nurse had charted a "Small skin tear not note worthy." I sent her out 911. She needed blood transfusions and was in the hospital 2 weeks due to the severity of her injury. I never found out what exactly had happened but i guarantee it wasn't a "non note worthy tear."
I quit at the end of that shift after doing copious charting and damage control with the family. My license is worth more to me than working at a place like that and nurses like that.
The point of all this is, that yes you get some amazing nurses at LTC facilities but you also get the bottom of the barrel too. LTCs let things like this slip through with little recourse. You cant get away with that type of thing at a hospital. That is one of the reasons people say the sharper nurses TEND to work at the hospitals, because you HAVE to be on your A-game. Those that arent find themselves jobless or reported to their BON.
Its really unfortunate. I would love to say that both areas are equally respected and take equal skill but they dont. LTCs get a bad rep because of nurses like I just told you about which have permeated that industry here in south Florida. They both have their challenges but the hospital nurses tend to be more "with the program" compared to LTC. Ive worked both so those are just my observations. :/
Things must be really different in Florida.....In Ohio our State surveys are more involved in SNF's than they are in hospitals. SNF's in Ohio do not "let things like this slip through with little recourse". Some hospitals in my area have nurses that I wouldn't let take care of my residents in my SNF. Unfortunately I have seen many hospital nurses that aren't even close to being on their A game.
It is comments like yours that keep this little feud between hospital and nursing home nurses going......
OK- as the OP, again I want to state in big HUGE letters, this is NOT about LTC vs Hospital nursing. I was spazzing because the many people empoloyed at this ONE specific NH had all gone along with this practice. That was the point I was trying to make. If I still worked in LTC, I'd be PO'D because it's things like this that give LTC nurses a bad name. Again, I am stating for the record that LTC nurses are mostly great, and make a big difference in their resident's lives. I was wondering how this might have gone through several shifts of nurses, as well as the Nursing Supervisors...This NH doesn't have a terrible reputation or anything- I was just aghast as to HOW something like this could happen? Is it because of short staffing? Is it because of new (or old) nurses? I know in the hospital now, we are not getting reimbursed for nosocomial UTIs by Medicare/Medicaide. I wonder who the appropriate "governing body" might be to contact about this? I find it appauling, as well as incredibly sad.
OP, this does seem very strange, but I do wonder what was going on with the resident that led to the staff doing this. Maybe there was a flip-flo or clamp of some kind on the catheter and the resident did pull it off. Unless the resident couldn't use his arms at all (and his general condition was most likely worse than usual if he was in the hospital - just because he couldn't do it when you saw him doesn't mean he couldn't have done it at the nursing home) I wouldn't agree that he wouldn't have been able to 'get at it'. I have seen many residents who won't leave their catheter alone, they pull on it, pull it out, disconnect the drainage bag repeatedly (by accident or deliberately), tangle the tubing constantly so that the catheter is almost always kinked and therefore not draining, and it goes on and on. Maybe the nursing home totally dropped the ball, it certainly seems like it on reading your post, but it would be very interesting to know the full story.
I have looked after a resident who disconnected the drainage bag from his catheter and let it hang free and open every time he had a shower, and he would disconnect and put his thumb over the end of the catheter if he wanted to change his clothes, and reconnect afterwards. No amount of advice, suggestions and persuasion from anyone (including his doctor) could get him to stop this practice. Over a couple of years his general condition gradually deteriorated and it was only when he was no longer physically capable of pulling the bag off easily and quickly that this didn't happen, and even then he would still complain that the staff weren't taking the bag off during his shower and when helping him to dress. I don't remember that he had any more or less UTIs than most residents with catheters.
Maybe I can help to answer the actual question. Mind you, this is not a good explanation, but it's an explanation. First, you said that the order was a clamping protocol, so that gets rid of the bag ideas. Maybe the buck stops at the DON of the facility. Maybe the DON doesn't know the protocol for a clamping procedure. Maybe she is the owner of the facility and doesn't want to spend the money on a clamp (I know, this is a dumb idea, but I have worked in some LTCs that still don't think it's a big deal to make sure there are gloves on hand cuz they are expensive.) Maybe the DON missed the whole infection control related to UTIs discussion in class. In going with this theory, one would think that the other nurses would correct the DON, right? Well, in some facilities, what the DON says, goes, because she is ultimately responsible over and above the other nurses, especially if she is the only RN and the rest are LPNs. Of course the LPNs would know proper procedure and infection control, but they are somewhat covered since they are under the RNs license, and if she said this is the way we are doing it, then what can they really do? Quit? That doesn't solve the problem. And considering the economy, many can't afford to quit. So the next choice for a nurse would be to call the dept of health and report this. An inspection by them could happen next week, next month, or 2 months away. So maybe an inspection regarding this resident was in the works but you happen to get them in your ER before they could step in and help.
By your post, it sounds like the DON didn't understand the clamping procedure or just didn't care? She is the leader. Maybe the other nurses just felt they had to follow her orders.
As for being reimbursed for nosocomial infections, it has been many years since I was an MDS nurse, but I don't remember this being a direct question. (MDSs are how SNFs are reimbursed.) Besides that, since it is a residential living facility, any and all infections that the residents get while being there can be considered nosicomial, right? That's a lot of nosocomial infections and if SNFs were not paid if this occurred, they wouldn't get paid at all for some residents who get infections often, or there would be months when there would be barely any reimbursement because the majority of the facility catches the flu or something.
Maybe this answers some of your questions, or at least provides another view to consider.
I think it could have been their last resort. As another poster mentioned we don't have the damn time to keep hovering over that resident and keeping their foley patent. Nor do our staffing levels allow for there to even be a CNA in there all night either. I had a resident who kept pulling her foley out and after about 4 or 5 times reinserting it.. we just got an order to discontinue it.
Not an option with this resident but I can see how he could get annoyed with a leg bag but .. a bedside drainage bag hanging under the bed.. he can't get at that.
First I'd like to say we don't even know who got him dressed. Maybe not an LPN or RN may have sent him out that way. I heard techs can do Foley care in some places and maybe an actual nurse hasn't laid eyes on it (due to staffing issues, no time). Also, dementia is not acute, it is chronic. He most likely did not have Alzheimers dementia but a different type. The man was presenting symptoms of delirium because of his UTI.
Hope the LTC takes advantage of the original poster's phone call and puts better practices into place. Sad that this patient had to go through all that.
Thinking on it some more.....I wonder if they disconnected the bag for ease of transport, leaving the cath in place d/t diff placement, knowing the hospital was going to replace anyway?
I think it could have been their last resort. As another poster mentioned we don't have the damn time to keep hovering over that resident and keeping their foley patent. Nor do our staffing levels allow for there to even be a CNA in there all night either. I had a resident who kept pulling her foley out and after about 4 or 5 times reinserting it.. we just got an order to discontinue it.
Not an option with this resident but I can see how he could get annoyed with a leg bag but .. a bedside drainage bag hanging under the bed.. he can't get at that.
Agree with this, although if the resident was annoyed by, and fiddling with, the catheter and the tubing, they could still disconnect a bag hanging under the bed, and the risk of pulling the catheter out altogether is still there. Is there any real difference between a resident constantly fiddling with their catheter and managing to disconnect it several times a day (and staff reconnecting it each time they find this) and leaving it open all the time? To me, both scenarios would seem to have a similar risk of infection.
Thinking on it some more.....I wonder if they disconnected the bag for ease of transport, leaving the cath in place d/t diff placement, knowing the hospital was going to replace anyway?
Nursing home are getting a bad rep, mainly because of cut backs, managers who should not be managers, and this reflects down the line! A bad manager is the captain of the ship. If steered in the wrong direction, its the patients who suffer. Not enough staff, or poorly trained staff affects the patients. Most nursing home here, are chain operated. Enough said.
iceprincess492
85 Posts
Things must be really different in Florida.....In Ohio our State surveys are more involved in SNF's than they are in hospitals. SNF's in Ohio do not "let things like this slip through with little recourse". Some hospitals in my area have nurses that I wouldn't let take care of my residents in my SNF. Unfortunately I have seen many hospital nurses that aren't even close to being on their A game.
It is comments like yours that keep this little feud between hospital and nursing home nurses going......