In St. Louis, the Labor Department has recovered more than $1.7 million in back wages for 4,000 employees of hospitals and clinics operated by SSM Health Care, a Roman Catholic system.

In Boston, the Partners HealthCare System agreed to pay 700 employees more than $2.7 million in overtime back wages to resolve a lawsuit by the department alleging violations of the Fair Labor Standards Act.

And under the proposed settlement of a class-action lawsuit in California, Kaiser Permanente would pay $7.25 million to hundreds of registered nurse coordinators, case managers and other medical workers. The employees said they had been denied overtime pay because they were improperly classified as exempt.

This is when they classify nurses as supervisors. They are, but they usually do not meet the federal standards for being exempt.

Nursing assistants, licensed practical nurses, janitors and cooks “are particularly vulnerable to wage violations,” Mr. Stripling said.

In many cases, employees say they were not paid for work performed during meal breaks.

“Most nurses put the patient first,” said Charles D. Boal, a registered nurse who worked in the critical care unit of The Western Pennsylvania Hospital in Monroeville, near Pittsburgh.

“We often gave up lunch breaks to see that a patient was taken care of properly,” he said. “If you brought your lunch from home or got food in the cafeteria and took it to the nursing unit, you would be interrupted by phone calls, by physicians and family members who wanted to talk to you. We really did not have an uninterrupted meal break.”

How many of us have given up a break, or shortened one, because of patient/resident care demands? I know I have. Multiple times. We need to MAKE sure we are being paid for those minutes given off our breaks. Don’t let the facility management con you into believing they don’t HAVE to pay you because a supervisor/other did not ASK you to give up break times.

Previously here, we posted an article for nursing assistants:
Getting Paid For Every Minute You Work

The changes, which go into effect on June 17, 2009, are intended to support efforts underway to transform nursing homes into “homey” environments through both environmental changes and resident-centered caregiving. Whereas in the past, these changes were sometimes stymied by fear that regulators would cite organizations for deficiencies, CMS is now making it clear that the OBRA regulations should be interpreted to support personal choice in the full range of daily activities, including waking, bathing, dining, and sleeping. The new guidance also calls for visitors to have 24-hour access to residents, regardless of familial relationship.

The new interpretive guidelines call on nursing homes to begin or to continue de-institutionalizing their physical environments. Suggestions include: reducing noise such as overhead paging and alarm bells, eliminating nursing stations, taking down institutional signage, and refraining from serving meals on institutional trays.

Get ready for the complaining. Eliminating nursing stations!?! But how can they expect us to do our work…But we can’t…and so on.

Pony up folks. Culture change is much needed process and we’ll all be better off with it. Allowing the residents to control their environment and choices is really a human right. Safety, and all those other excuses we tend to use, are just that: EXCUSES. We don’t want to give up our “power”. It’s not about us. It is about our customers- the residents.

Some Culture Change Sites of Interest:
Pioneer Network

Check out the PN’s vast selection of resource links HERE.

Just one section, which is VERY pertinent:

I have found that some people are easier to train as aides. Those who are very perceptive do not need to be drilled. But I wonder if nurses’ aide trainers now have realized that some of their trainees do not possess the social skills that most of us learned growing up. With single-parent families and families with two working parents, it is probably more difficult to teach social skills. Also acceptable social behavior has to be taught at home and reinforced in the schools.

Some younger nurses’ aides have not learned these social skills. Today we live in a casual society where we are not required to dress appropriately for very many of life’s events. Schools do not usually have dress codes. Years ago, aides were required to wear specific uniforms usually pressed to perfection. Like nurses, their hair had to be off their collar and their nails had to be kept short. Today’s rules now are not nearly as stringent, or aides reject them soon after training. The common sense rule of a clean and relatively wrinkle free uniform is important. Many aides have nails that are too long. Artificial nails are fine if they are kept at an active or sport length.

A recent article stated that most young people would benefit from reading a Miss Manners’ book. That same idea would be helpful for nurses’ aide trainees. Knowing etiquette and using proper manners make life easier. It is never too late to learn what is proper in order to feel comfortable in most situations.

PLEASE read the whole thing; whether you’re an aide or one who trains them, a DON, a nurse…I know a lot of this will ring some bells! Leave Kathy a comment, too- share your thoughts on this with her.

These are Residents Rights, with info and guidelines for CNA’s to follow when caring for residents after the first few.

The right to be fully informed—by word and in writing—of the policies and procedures that protect the person’s other rights

All of the rights of citizenship the person has in the United States
This includes voting in all elections.

The right to know all of the services available at the facility, including whether it is certified for Medicare or Medicaid residents, and the right to assistance in applying for those benefits

The right to be fully informed about the person’s own health condition
Believe or not, some residents do not know what their medical conditions are. Some families wish to keep this from the resident. Or, residents are not informed of disease progress (such as a cancer spreading). While the CNA should never disclose this information to ANYONE, we need to be extra careful when discussing it at the Nurses’ Station and other not-so-private areas.

The right to choose one’s own physician

The right to refuse medication, treatment, or care
Indeed. A resident can refuse to be medicated, to have dressings changed, to be weighed, bathed, fed, dressed- we cannot force them to do these tasks or allow us to assist them. When we do, against their wish, we are violating their rights and in some cases it would be considered abuse. It is very important to document these instances. Make sure the nurse is aware of the refusals.

The right not to be forced to perform therapeutic activities
These include PT or OT sessions, activities, special baths and the like.

The right to be free from punishment and involuntary isolation
THIS IS A BIG PROBLEM. CNA’s often take it upon themselves to remove residents from dining and other rooms and place the resident in their room. This is involuntary seclusion and in some cases is considered abuse. Don’t do it. Wait for the nurse to direct you on this. It is never within the scope of a CNA’s practice to make decisions like this. Withholding food, drinks, delaying care, when used to punish a resident is abuse.

The right to be free from verbal, physical, sexual, and mental abuse
For some residents, the sweet little nicknames we have for them is a form of verbal abuse. Others love to tease and tell jokes- but for some this is mental abuse.Yelling includes raising your voice. Or using short, sharp words- it’s all verbal abuse. Many aides don’t understand the varieties and the subjectivity of this. If it offends a resident, often it can be called some form of abuse.

The right to be free from chemical or physical restraints except on a doctor’s order and as a last resort for the person’s safety
This includes being put to bed against the will. It also includes placing residents into recliners and other furniture that they cannot freely get up from. Being tucked into a table so close movement is not possible is a restraint as well.

The right to be treated with courtesy and respect
Manners. Use them. All the time. Please, Thank you, Excuse Me, I’n Sorry. Referring to Sally Smith as Mrs. Smith until she asks you to use another name…

The right to privacy when receiving treatment or personal care

The right to get and send mail and to make and receive phone calls without anyone else’s interfering

The right to associate with anyone the resident chooses, in private if the resident requests privacy

The right not to be sent to a new room without a good reason, advance notice, and sufficient preparation

The right to keep medical and personal records confidential (except as needed to evaluate the facility and follow up on complaints about your care)

The right not to be transferred or discharged without good cause, advance notice, a discharge or transfer plan, and the right to a hearing to stop the proposed change

The right to make suggestions and complaints and to have the staff act promptly in response, and the right to be free from retaliation of any kind for making complaints or suggestions

The right to inspect the person’s own records, and the right to purchase copies of all records

The right to participate in any social, religious or community activity the person chooses

The right to keep and use personal clothing and belongings, as space permits, and to have lockable storage space for personal belongings

The right to be reimbursed for belongings lost or stolen by facility employees

The right not to sign any contract or agreement that claims the person agrees to give up any of these rights

Some of the things I do to make sure I’m ready and physically able to do my job are pretty mainstream, or so I thought. Lately I’ve noticed newer aides not bothering to do simple things that can make such a difference.

1) The usual items we hear about are par for the course: Eat right, exercise and get plenty of sleep! Easier said then done in today’s busy world. Family, friends, commitments, kids’ games and activities all keep us, at times, TOO busy to care for ourselves.

2) We use our legs, arms and backs for the vast majority of the tasks we perform. It makes sense to stretch these muscles before we use them. Before I go to work, each shift, I do some simple little stretches and exercises that really have helped me stay limber, and I believe they help me perform the lifts and other harsh aspects of this work without pain, and without injury. Please seek your doctor’s opinion before attempting these. The links take you to a site that illustrates how to do the stretches.

SHOULDER STRETCHES

UPPER BACK STRETCH

LOWER BACK STRETCH

SPINE ROTATION

HIP FLEXORS

I do three sets of 10- if you haven’t stretched in a long time, do less.

Finally, I always have on my person, a bunch of things that might be needed (and from experience, have indeed BEEN needed!)…A small bottle of Tylenol/Advil/Bufferin or whatever pain reliever works; some TUMS, a little bottle of IMODIUM; band aids…all travel size bottles or packages- that fit neatly in my bag or in the glove compartment. One never knows when the headache from you-know-where will come along; it’s good to have some relief on hand.

What things do you do to stay healthy, as part of your lifestyle or specific things for work only?

Question:
At work today I got into trouble because one of my residents’ fell. This man is independent and never needs our help. He can do his own care- showers, dressing, walking, meals, toileting…the works. As far as I know he has never fallen before. I was busy with one of my other residents who requires total cares. I was in the middle of bathing her when the nurse came in to tell me the man fell and why wasn’t I with him? After I finished up with my lady’s care, I was told to fill out a report which wanted to know what I COULD HAVE DONE to prevent the fall; THE LAST TIME RESIDENT WAS TOILETED; THE LAST MEAL consumed- all things that had nothing to do with this fall!!

Later, I was written up for the fall. I told the DON that everyone is responsible for ALL the residents on the hall I was working. Yes, he was assigned to me, but when I am busy with other residents, my co workers should step up and cover for me. What do you think of this?

Answer:
You should not have been written up, in my opinion.

Every resident must be assigned to a CNA. It’s law. No way out of that. Every aide accepts their assignment and therefore responsibility for the residents on it. Each CNA is responsible for her assigned residents and the unit, as a whole, cannot do this.

It’s tough when bad things happen to good aides, though.

Did you read the man’s care plan? Are you absolutely sure he is independent in his cares? If so, did you check in with him to see if he needed any help, with anything? I think sometimes we assume these residents who are able to do their own care never need ANY help- and this isn’t always the case. When doing this check in, it’s always a good to ask when they’re planning to get up; what they’re bathing plans are and the like. This way, you can have some awareness that Mr. Smith is going to be up and about around 9am, and might need someone to just peek at him.

Of course this is where team work comes into the picture. Every time an aide is going to be tied up for awhile with residents, its always a GOOD thing to let as many peers know where you’re at. And include the nurse with this info as well. If you’re so inclined (and I would be) I would ask peers to keep an eye and ear out for your other residents…especially if I was going to be tied up for a longer period than usual with the other resident. A good charge nurse would make sure your other residents are covered as well. It’s a balancing act though: Asking every aide to cover the others’ residents every time personal care is being performed is just not practical.

As for the report: It’s called an Incident Report. The questions asked do indeed have everything to do with the assessment of a fall. By asking you what you could have done to prevent this fall, the answers you provide are supposed to be helpful to prevent a repeat in the future.

Did you know most residents fall because they are trying to get to the bathroom? If they’re hungry they might be trying to rush out to a meal. Usually there are other questions too on these reports- about all sorts of things. Often we don’t know the prior condition of any resident when they have fallen without a witness.

It’s very important for CNA’s to answer these things honestly…however….when we’re written up it takes away the desire for CNA’s to have any respect for these reports. These things should never be used as a means for punishment. When independent residents fall, it is NOT the direct fault of the aides. It was caused by something else. It IS up to management to figure out why the fall occurred- but by placing blame on the aides they are short changing this process. This is another example of autocratic management style- which isn’t helpful. And, I have to wonder if nursing homes with high fall rates have these kinds of managers.

I’m sorry you got written up. Of all the things CNA’s don’t have control over, the FALL tops the list. The work loads alone should tell all that it’s impossible to be everywhere at the same time- or even once an hour. A good fall prevention program begins with a trusting environment where no one is disciplined for falls unseen. Once that is in place, true prevention strategies can be developed AND the CNA’s are the most valuable asset to this process.

However, at work, in nursing, they are fast becoming a nuance. I see many nurses and aides who constantly check their cells for messages; or who are texting someone. Right in the middle of patient care! Or a residents’ mealtime!

Message to CNA’s:
Cell phones no longer interfere with most medical equipment. This is no excuse to use them while we are working. Surely any message can wait until a break. Nothing is more aggravating than watching your co-worker drop everything they’re doing to TEXT someone. Or to check a call. Not only is this aggravating, it’s very unprofessional.

Message to management:
What is YOUR policy on this? Where I work we are not allowed to carry our cells with us on the units. Equipment problems are not the stated reason either. Rather, common courtesy and professionalism are cited. Cell phones take time and attention away from resident care; residents and co workers perceive the use of cell phones during care as rude (IT IS!). Staff are allowed to use their cells on their breaks only, and in the break room only- not in patient care areas.

Question:
At my facility we’re not allowed to call out! Lately there’s been a lot of call outs and even more aides quitting. So we work short all the time. A couple aides have hurt their backs too cause we’re short all the time. Anyway I got the “bug” last week and had a fever, vomiting, and diarrhea. I felt horrible. I couldn’t eat anything; I couldn’t keep anything down. I called work to let them know I would be out for my shift and they put me through to the DON. who told me to come in for work, to report to her prior to clocking in so she could assess whether I was too sick to work. If I didn’t follow this directive, I would be terminated. SO I went to work and the DON took my temp (101.2)- she gave me Tylenol and a couple spoonfuls of Pepto Bismol; she told me report for duty. If I didn’t feel any better in an hour to come back and see her.

Is this legal???

Answer:
Your email tells me your employer is having a hard time with staffing. It appears that the place is going through a downward spiral of problems and management is part of that. When an aide shows up for work, sick with fever and infection, she exposes not only the residents, but her co workers as well.

It’s very likely more than a few will catch the illness. So, it spreads like a fire. As each aide comes down with the bug and misses work, management feels it has to do something to curb what it perceives to be an abuse of attendance policy. Management should be prepared for a staffing crunch knowing a virus is going around. But, this facility’s management is punishing the very people who are out in the battlefields where the germs are located. It’s old fashioned and autocratic.

Instead of being proactive, the DON is being REACTIVE and in a very negative manner. Her actions are telling her staff that she doesn’t trust their judgment on their own bodies health. She is also telling them she has no respect for them. A warm body on the schedule is all that matters, even if that body’s temp is 101.

The Legality of this:
If this is a policy, it must be written as such.

I called a lawyer friend and relayed this scenario and she gave me the following advice: Is the DON a doctor or a Nurse Practitioner?? If not, she is straying from her nurse practice laws. Nurses cannot diagnose illnesses, diseases, disorders and the like. Perhaps she is sending staff to a doctor who is legally licensed to perform a medical assessment. She would be smart to do this. She should NEVER give staff ANY medications without a doctors’ order. She is putting her license on the line by doing so. She knows this. And is counting that you don’t know this.

Legally this practice is not advised for management. They are risking a discrimination lawsuit if this “policy” doesn’t cover ALL employees of this facility- so, when the dietary aide or the cook or the maintenance man calls out, the DON/Management must apply this same requirement towards them. They too must come in, be assessed, and determined if they’re “healthy” enough to work or not. And this would mean doing so 24 hours a day, 7 days a week. Even on holidays and weekends.

What To Do?
If you find yourself too ill to perform the duties of your job, you can and should call out. However, you should also make every attempt to get better or try to reduce your symptoms so you can work. In other words, do take Tylenol/Advil to get the fever down. Immodium will end just about every episode of diarrhea. After this, if you still feel too sick, call out. Make sure you follow the policy- most facilities require 2 or 4 hours notice.

Have your spouse or a friend make the call for you if you’re concerned with being harassed by the DON. Instruct your spouse/friend to take a message but to be firm: You will not be showing up for work. Make sure your reasons are given: Details- fever, vomiting, ect. and the actions you have taken to try to make it better. Then call your doctor and make an appointment. You’ll need to be assessed and diagnosed properly; and the MD will need to write you a note excusing you from work. Often, this note will include actual dates you are not recommended to work.

A doctors note will not protect your job.
We need to know this and not rely upon it. The note does give credibility to you though: You’re putting the effort into seeing the doctor to find out what is wrong and get better; you’re paying money to do in most cases; you want to show your employer you weren’t goofing off, ect.

You can still be terminated unless you’re a member of a union which has rules on this.

I would not wish to continue employment at a facility where this practice occurs. I would leave on my own free will and seek employment at another place with more enlightened management.

When working short, there’s a saying among aides: Face, Hands and Butts. FHB. This means that our time should be spent washing faces, hands and butts and the rest can go unattended. This isn’t ideal but it is the reality when we’re pressed for time.

Even when our units are well staffed I have seen some pretty poor quality cares that leave me wondering if some of us cannot put ourselves in our residents’ shoes…

No matter how short staffed, we must always consider resident dignity.

Complete bed baths, whirlpools and showers can be postponed.

Washing faces doesn’t mean simply wetting a wash cloth and wiping it over a face. It means using gentle soaps/cleansers. It means using another wash cloth dampened with water, to rinse off the soap. It means paying close attention to the eye areas, removing the residue and drainage we often see. It means making sure noses are clean and the area around mouths is clean as well. Shave the men.

Oral care MUST always happen- how would YOU feel if your teeth weren’t brushed???

Care must be given to underarms. They need to be washed, rinsed, dried. If needed, a light coat of deodorant is called for. Body odor is a major dignity issue for our residents.

Hands have to be washed. Period. Several times each shift. Nail care can wait, unless they are long and ragged or dirty.

Incontinent care has to happen. Buts and other areas MUST be cleaned. Period. No skimping here.

I can’t count the times I have witnessed residents being brought out with messy hair, or worse, with hair dos that are not becoming to them. Ladies like to look presentable. Imagine how you would feel with greasy, slicked back hair…it’s up to US to make hair look nice. Hair should be combed/brushed no matter what; if ladies’ hair is permed, a little spritz with some water often works wonders to bring back some curl.

Clothing choices? It usually doesn’t matter when it comes to staffing issues. Residents have clothes and we assist them with dressing. BUT what does matter is matching colors at best and avoiding clashes at worst: Striped shirts do not go with plaid pants! Just like an elegant fluffy blouse doesn’t go with sweatpants. Some of our male residents prefer to wear t shirts under their tops; and MOST of our ladies like to wear bras. Don’t skimp on this.

A quick note about briefs: For the residents who use them, we have to ensure they are correctly applied. The right size is paramount. Too big a brief is not only wasteful but a major cause of discomfort. Small briefs often lead to nasty red marks in the groin areas. Make sure the brief is centered, and the front portions are pulled up enough to allow for movement. Don’t let the brief bunch up anywhere.

Residents who use wheelchairs need special attention for comfort AND skin issues. This is a no brainer but I have seen countless times, bunched up shirts in the back and sides. Pants that are wedged up in front. We need to make sure these things don’t happen. Take the time to pull down tops once a resident is positioned in their W/C; fix the wedgies and pull down the lower parts of pants. Make sure the resident is seated properly and is comfortable.

As much as most of us don’t like providing less than ideal care, we can do so on shifts where we just don’t have time. Assignments are often increased with two or three residents when there’s been a call out. Always check with the charge nurse about your priorities when staffing is an issue. Better yet, ask the nurse for a meeting with all the aides on the shift, to plan ahead for those times.

Always consider safety, comfort and dignity. Some will say not always in that order, either.

1. Interviewable sample resident #2 was admitted to the facility on 2/6/01 with diagnoses including rheumatoid arthritis and a thyroid disorder (according to the face sheet). The quarterly Minimum Data Set, dated 6/12/07, coded the resident as having mild short term memory loss.

Observations of the resident on 7/1/07 at 10:30 a.m. revealed a certified nurse aide (CNA) was preparing to transfer the resident from her bed into a wheelchair using a Hoyer lift. The resident stated she needed to go to the bathroom prior to being transferred. The CNA stated the resident experienced pain using the toilet in the bathroom, so he had her go in the trash can by suspending her in the lift and placing the trash can underneath her.

A follow up interview was conducted with the CNA at 1:55 p.m. The Unit Manager was present during the interview. Both stated the day shift and evening shift used this method to toilet the resident. The Unit Manager stated the night shift had the resident use a bedpan, and did not get her up.

And:

On 7/1/07 at approximately 1:00 p.m., supplemental sample resident #27 was heard calling for help in a loud voice. The resident was seated in a wheelchair in the Silver Key office and appeared in no distress. There was a CNA seated in the Siver Key (sic) office with the resident. The CNA stated that was her job for the day, to sit with the resident. The resident could be heard calling for help in the hall outside the office. The CNA asked the resident several times why she was calling for help when there was nothing wrong. The resident yelled for help again and the CNA stated, “You are just a problem child.”

In the first example. the staff used a mechanical lift and trash can to assist with toileting a resident. Is this normal? Is this digified? What are some options?

Commodes: They make commodes in all sizes and shapes, out of soft and hard plastics. Most CNA’s have seen these PVC models. The CNA’s are the resident’s advocate. In this case they should have (and perhaps did) ask for a comfortable commode for this resident to use.

Bed Pans: They also come in many shapes and sizes. Some are made of softer plastics as well. The CNA’s should always encourage the resident to use this before getting OOB.

In the second example things aren’t so clear. Just the name of this room suggests dignity is an issue. When a CNA is expected to be a sitter, they need to have clear expectations of what they are to do with the resident. Just sitting there and watching them often isn’t enough and is very undignified. Usually a resident who needs 1:1 supervision really needs to be occupied. To be kept busy and somewhat distracted.

The CNA’s working with this resident could have foreseen situations where 1:1 time would be needed; and anticipated the need for activities and other things to do. Seeking the help of the Activity Director or other person, puzzles, board games, reading materials or any number of other items could have been available. Smart aides know these times will come and have a box of items at the ready for these moments.

We never tell a resident they are a “problem child”. To do so is border lining on verbal abuse.

To wrap this up, when we are caring for a resident who has special equipment needs for ADLs, ask to see one of the medical supply books to see what is available. If you find something that will work ask for it to be ordered.

Plan ahead. Anticipate needs. Ask for equipment. If your facility employs the services of a physical and/or occupational therapist, seek out their input on resident comfort and equipment issues. Document all of this in your personal log. Ask the charge nurses to document equipment requests in the resident’s medical records.