Approved scenario: AV is an RN with under 1-year experience. She works

AV is an RN with under 1-year experience. She works at a skilled nursing facility/nursing home on a floor with mixed patients/residents, long-term and rehab. She works the 3 pm to 11 pm shift. The floor is staffed with 2 RNS and 3-4 aids from 3 to 7, so she has 20 patients to care for, and 1 RN and 3-4 aids from 7 to 11, so another 20 patients are added, and she cares for 40 patients from 7 to 11:30 pm. Her tasks are to assess/take vital signs of all the residents/patients once per shift, full-body skin assessment 4-5 residents per shift, pass medications (6-7 patients on each side are taking narcotics), implement skincare or supervise aids who implement some of the care, admit patients, receive medications from the pharmacy, report to physicians changes in health status, and get telephone orders, answer internal and outside calls. There were 2 falls during the previous shift, and to her usual tasks a monitoring protocol with frequent assessments and vital signs every 30 minutes, then every hour on two residents are added. Also, there are two confused comparatively new residents, who are on bed alarm and continuously trying to get up. There is one resident in a wheelchair whose depression worsened, she is crying that she does not want to be there and trying to escape. One of the aids blocked the door out of her room to restrict her from escaping the room, saying that she makes havoc and disturbs other residents. Because of the disturbance that she causes he cannot complete his daily tasks of feeding and assisting residents to the bathroom. Bed alarms get off every 15-30 minutes and the nurse rushes to the call to prevent the fall when she can. One of the assistants keeps disappearing and the RN notices that she avoids being called behind the curtain in the room with the dying resident on hospice, where she was noticed napping in the chair once and looking at her phone another time. It is 8 pm, the RN and 3 aides have 38 residents/patients in 2 wings when a new admission arrives. The RN asks for help from another floor, as the supervisor who left at 4 pm told her to do if she needs help, but the nurse on the other floor is in a similar position and cannot come to help, advising the overwhelmed AV to do what she can and then someone will help. AV understands that inadequate staffing puts her in a situation when it is impossible for her to give nursing care according to standards of nursing practice. As a result, she misses the after-fall assessments, she is behind with med pass, and one of the patient’s skin assessment discovers a quarter-size new ulcer on his toe, that was not reported in the skin assessment from yesterday. It could not have grown to this size in less than 24 hours! The nurse on a previous shift must have missed the skin assessment possibly because she was overwhelmed with a load of assignments or asked an aid to check the integrity of skin when he gives a routing foot care at bedtime (which is not the right thing to do – she could not have delegated the skin assessment) and the aid said everything is fine while it can be inferred, that it was a lie and he did not give the foot care, or he would have seen the big ulcer yesterday and it would have been reported yesterday.

Many issues arise from understaffing. I will be writing about dilemmas that a nurse is posed by the unreasonable institutional standards of staffing and expectations, and ethical implications. I am going to use what I already researched while writing an HPM re: nurse-to-patient staffing ratio in long-term care facilities.[supanova_question]