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My thanks to a certified nursing assistant (CNA) for sharing the following information regarding her very personal (on the job), experience as a nursing home employee. As a CNA, she is truly on the front line of providing care to residents. If her story doesn’t make you angry or concerned or whatever-enough to do something about the problem of nursing home UNDERstaffing, I don’t know what will motivate you. Our anonymous CNA writes…

“I got my CNA license three months ago from a local certification program. Then I got my very first CNA job two weeks ago (August 2011) at a nursing home. I’m here to say that I am appalled at the conditions there in my new place of employment. I’m told by by co-workers that this situation is “normal.” As you read this information, try to imagine if your mother were a nursing home. My post here is a cry for help!

There are 35 residents on my floor, and during the 3-11 shift (my shift) we have only 4 CNA’a. One of the residents on our floor is paralyzed, requiring mechanical lifts –that means she cannot be lifted out of bed or out of a chair without the use of a sophisticated mechanical lift known as a “Hoyer Lift.” And the law mandates that whenever a mechanical lift is prescribed, such a resident gets designated as a “2-person assist” which means that resident will always require 2 CNA’s to lift him or her for whatever reason (showering, toileting, etc). The “2-person assist” is a serious designation! Major legalities apply here!

Meanwhile, another resident is permanently bedridden. Whenever he needs to use the bed pan (about 5 times a day) it likewise takes two people to toilet him there at the bedside. Another resident is semi-paralyzed, so she’s a 2-person assist to get her on and off of the 3-in-1 shower chair (portable comode) where she gets toileted. Another resident is moderately overweight, but is about 90 years old and has no strength in her legs, so she requires a different type of mechanical lift (a Vander Lift) when she needs to toilet. Once again that requires 2 people. That right there means four residents on our floor are designated as needing “2-person assistance.” And more than 80% of the remaining residents (26 of those other 31 residents) are classified as needing “1-person assistance,” which means 1 CNA must help them sit and stand and transfer from their beds to their wheelchairs to toilets, etc. The most frequent need of the 1-person assist residents is the need to be walked to the toilet.

Every time a CNA helps a “1-person assist” resident to toilet herself, that’s a time expenditure of no less than three minutes. An awful lot of tragic things can happen with the 34 other residents in three minutes. (Would you leave a young child alone for 3 minutes? If your answer is no, then why on Earth would you leave an 82-year-old alone for that long?) Every time two CNA’s help with a “2-person assist” resident, it ties them up for no less than 5 to 9 minutes, and only if they are very fast and very skilled. Trying to get an incapacitated person into a Hoyer Lift is VERY dangerous and time-consuming, but it MUST be done, and you don’t cut corners with a Hoyer! That’s 9 whole minutes. What if a pair of CNA’s are mid-way through a Hoyer Lift procedure right when 3 of the 1-assist residents on the same floor all ring their call bells at once because they each just happen to need to go pee at the exact same time? It happens. I have seen five call bells at once go off, but there are only four CNA’s on the floor, and half the time two of those CNA’s are tied up with a 2-person assist resident … for up to nine minutes.

So what do you imagine will happen if a 73-year-old lady needs to pee but no one answers her call bell? The answer is either a) she’ll pee in her pants, or b) she’ll try to walk to the bathroom on her own. The first answer is bad because peeing her pants can set her up for things like urinary tract infections and bed sores, not to mention that it’s just a horrible degrading thing to pee oneself. The second answer is worse because she might fall. If she falls she’ll likely break or even shatter a bone, and then that CNA is in a world of trouble and she could easily lose her license.

Does any of this sound fair to you? Is this fair to the resident? Is it fair to the CNA?

Helpless is helpless, no matter how old. I see many great strides take on behalf of childcare standards, but so little is done for elder-care standards.

A CNA will get in major trouble (as in get suspended or fired) for leaving a resident unattended in a Hoyer Lift. So once that CNA has a resident in a Hoyer, she cannot leave that Hoyer Lift resident for the sake of answering a call bell. Meanwhile, at the other end of the you’re-going-to-get-in-huge-trouble scale, a CNA will also get burned for not answering a call bell quickly enough. The call bells have timers, so as soon as a call bell gets activated, a computer records how many seconds (or minutes or hours) pass by before the bell gets answered. The facility can calculate the overall average of how long it takes for call bells on a given shift to get answered. So a CNA could get fired and lose her license for having a terrible average in her call bell response times.

Then there’s the threat of “decubitus ulcers,” — that’s the official medical term for “bed sores” (a/k/a “pressure sores”). Bed sores tend to form most often on the coccyx (tailbone), and sometimes on the elbows, knees, shoulders, anywhere on the spine, and even on the heels and the soles of the feet. Boney areas are the key here for figuring out where they’ll form. If you are lying around all day long, or sitting for 12 hours straight in a wheelchair all day, the constant pressure and lack of circulation start to degrade the tissues of those areas –and in a battle between bone and muscle, bone usually wins. The muscle and skin tissue slowly break down (that’s the beginning of a sore) and then the bone eventually starts to poke through. As any dentist can tell you “Bone CANNOT touch air!” Bed sores are very dangerous, prone to rapid infection, and can easily kill you. Once a bed sore is detected, the CNA’s and nurses MUST go on the offensive to combat that sore with a vengeance to prevent it from getting any bigger. Then they embark on the long, arduous process of healing it. Google for “decubitus ulcers” to see horrible photos of such sores. They can range in size from a few millimeters to over a foot in diameter. The big ones can maim and disfigure you for life. They can even kill you in mere weeks.

The way to prevent a decubitus ulcer from even happening is to engage in frequent and regular “reposition” an unmoving resident. Repositioning is done once every 2 hours. This relieves pressure, allows circulation to flow again, and the tissues that were being squashed can start breathing again. I was told during training: “It takes four hours for a bed sore to form and four weeks for it to heal.” The task of repositioning is a very straightforward one, sometimes requiring two people and about 1 to 2 minutes of their time. I have NEVER seen it done this fast at the nursing home where I work. Meanwhile we are supposed to fill out forms at the end of our shift where we record every instance of having repositioned someone. We all have to fill in the forms every night where we CLAIM that we did repositioning every 2 hours for every last one of our assigned residents. But we didn’t. None of us did. So those documents get falsified every time, every shift. I wish I had the time to do all these repositions during every shift.

I wish I had the time to do a thorough skin examination of each resident assigned to my care during every shift. But I do not. None of us do. I accidentally discovered a blank form last week called a “CNA Skin Sheet.” I’d never seen it before (no one showed it to me during my training period). The form has a simple drawing of a naked human body, front and back, on which we CNA’s are supposed to record places we see skin problems on a resident. It’s kind of like “mapping” their skin anomalies. The other CNA’s said “No one does those anymore.” (Because no one does skin checks anymore.) So now I’m waiting for the day when we all get the memo that a resident came down with a massive decubitus ulcer. The best I can hope for is that maybe the other shifts have time to do checks. But I doubt it.

It breaks my heart to know I’ve no time to care for the residents the way they should be. It kills me whenever I see a call bell go unanswered for almost 15 minutes.

Every time a CNA in my facility clocks-in at the start of her shift, she’s taking the risk that something will happen where someone might get injured or killed, and she herself might lose her license. Meanwhile, the other CNA’s likewise hate this insipid reality we have to deal with, but they’ve been here a long time and tell me it’ll never get any better. They’ve all developed a dark, jaded attitude. “You’ll learn” they mutter.

Nursing home understaffing is considered by many to be “normal” — as long as facilities can continue to get away with it. It all comes down to money. Why have six CNA’s on the clock when you can get away with just four?

Meanwhile, if there’s an MBA-trained number-cruncher reading this — the kind of 26-year-old snot-nosed kid who wears a suit and never once had the privilege to put on a latex glove, and who does nothing but look at PowerPoint graphs of employee cost analysis — YOU are to blame here! YOU are the most culpable party in this whole shameful debacle! If you are one of those MBA-holding snobs who stands smugly behind your laptop, pointing at a screen while saying: “According to the parameters of this particular matrix, which is a fine chart laid out by the American Nurses Association, 4 CNA’s should be enough,” then this is on your head –4 CNA’s is NOT enough to handle 35 people, especially when 4 of them are 2-assists, 26 of them are 1-assists, and three of them are chronic wanderers!

If there are any journalists or politicians reading this, you NEED to take notice of this crisis–and it IS a crisis. It’s a risk-management crisis akin to the BP Gulf of Mexico disaster of 2010. BP had a reputation for decades in the oil industry as being one of the worst offenders of safety violations out there. But they got away with it for so long because of lax oversight, extreme cost-cutting, and 7-digit bonuses for the suits at the head office if they could squeeze an extra basis point out of each quarter. This situation with too few CNA’s in American nursing homes is exactly the same. Different industry, same problem.

Just like BP, nursing homes suffer from all of the following: deficient safety standards, poor oversight, bonuses for “the suits” for cutting staff to the bone, and a false security found in the sheer luck of having not yet had an accident severe enough to garner worldwide attention.

Just one fall. Just one overlooked laceration. Just one accidental strangulation. Just one covertly executed suicide attempt. Any one of these can easily happen in the span of just three minutes while some poor overworked CNA is helping an old lady use a toilet.

The nurses in nursing homes are in just as bad a situation because they also are overworked and understaffed. Their liability is twice that of the CNA. But in a nursing home setting, the CNA is the true point-person when it comes to providing adequate one-on-one care (in a hospital setting it’s the nurses who are the key).

I MUST tender my resignation. I can’t in good conscience continue to take part in this horrible management-spawned scandal of neglect and fraud. I have had nightmares about my place of work and I’ve only been there since August 24th. Perhaps I will go into private duty. There are no benefits to private duty, but at least I will be able to sleep at night. This decision to resign is my own effort at risk-analysis here –I am weighing out the risk between A) staying at this place with benefits where I am undermining my heath and running the daily risk of losing my license, vs. B) going into a more rational work environment with no job security and benefits. I’ll take the latter.

I hope to see reform in the industry soon, and if it comes, I’ll gladly return to nursing home work. But I hope it won’t take a world-famous BP-style tragedy to trigger such reform. However, I fear that’s the ONLY thing that can bring it about. The politics of American policy-making has always tended toward a reactionary mindset, never a proscriptive one.

I hope someone with even a small modicum of power can read this thread and help to bring about the changes needed. I am a ………

Shocked & Awed CNA (Massachusetts)”

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