What Does Bad Care Look Like?

By Carrie Mortrud, RN

Carrie Mortrud, RN

Carrie Mortrud, RN

In our efforts to alert regulatory agencies to the nurses concern for quality patient care in MN hospitals, we created categories to sort the concerns that are submitted by our members. As a follow up to the nurses’ action at the 2015 Minnesota Nurses Association Day on the Hill, MNA delivered thousands of concern for safe staffing forms to the Commissioner of Health. We’ve had ongoing conversations with the department, and researchers there asked that MNA assist in categorizing or organizing the forms into meaningful categories that could be easily understood. Let me explain the categories, and what they mean. Stay tuned for a year-end report and comparison to 2014’s concern for safe staffing submissions.

MNA has created categories to better track and analyzes the forms nurses submit when there are staffing issues in their facilities. Nurses have been alerting their managers, supervisors, and even top-level administrators to their concerns around patient safety in the form of a Concern For Safe Staffing Form for over 15 years. To make analyzing and tracking trends more convenient, MNA staff developed categories based on the reports nurses submit. The data entered on the forms and the description of communication with management has provided great information for nurses and MNA to document this systemic crisis.

  • Delays in cares or treatments or incomplete assessments. This means a patient waited for a nurse or a nursing assistant to deliver cares in the form of treatments like dressing changes, assistance with breathing exercises, walks in the hallways, IV site rotation or the nurses was unable to complete a full comprehensive assessment upon the patients arrival.
  • Delays in medications. In this instance a patient waited for pain medications or their scheduled medications were late or delivered past the time they were due.
  • Inability to answer call lights. Nurses and nursing assistants were unable to answer call lights when patients or patient family members put them on asking for help.
  • Incomplete discharge or rushed teaching. In this scenario a patient was discharged without their discharge teaching being completed or the teaching was rushed.
  • Management staffs by ratios. In this situation the nursing staff requesting additional nursing staff was either bartered with or was denied more staff because management stated the unit’s staffing grid/matrix/staffing plan did not allow for it. Or they were told they could get more help if they took another patient(s). Completely ignoring professional nursing judgement in relation to how sick the patients are and the experience level of the nurses delivering care.
  • Management works the shift.   Qualified or unqualified, nurse managers came and worked the shift to fill the staffing vacancy or need.
  • Managements response is NONE or inappropriate. This records the number of times management either never responded to the nurses’ request for more staff or they responded with comments like, “Well, at least no one is dying, so it’s not that bad,” or “we are just going to cross our fingers and pray no laboring mothers to be come in.”
  • Extreme overtime greater than 16 hours in a row within 24 hours or multiple doubles in a row. Nurses have been pressured and required to work 17, 18 up to 22 hours in a row because there was no one to take over their patient assignment. Some nurses have worked multiple doubles in a row in order to attempt to provide care for patients.
  • Patient falls or patient safety is at risk. Nurses reported that patients fell or their physical safety was at risk, i.e. no one was available to watch them because of the staffing situation.
  • Patient left AMA or without being seen.   This tracks how many times patients leave an emergency room or outpatient service center without being seen by a health care provider or left against medical advice because of the delay in treatment, care or inability to receive care.
  • Short staffed greater than 25% of what is needed. This category describes situations in which the staff that the nurses report is present is 25% or greater below that which is necessary to meet the patient care needs.
  • Temporary solution-closed the unit to admissions or transfers. In a unit closure situation, the nurses temporarily closed the unit to admissions and transfers in order to regain safety for those patients already admitted and in their care on the unit.
  • Temporary solution-refused the assignment. These situations are where the nurses, in their professional judgement, determined that the patient assignment they were given was unsafe and reduced quality to a position where no patient in their care would be receiving quality care.
  • Temporary solution-obtained the appropriate number of staff. This category describes that when the nurses requested additional staff for patient care needs, the additional staff was provided.
  • Unqualified staff-nurse pulled off orientation early. This scenario describes the times in which management has taken a nurse off orientation before it is completed and given that nurse an assignment solo. They are no longer assigned an assignment along with their preceptor simply because there are not enough nurses so they cut the orientation short because of short staffing NOT because the nurse is ready to come off orientation early
  • Unqualified staff-nurse not trained to the unit or equipment. For example, OB nurses were sent to work in the Emergency department. Here management sends just anyone to fill an opening. Many times nurses who do not have experience on a particular unit or with specific equipment are asked to work in these patient care units. This puts patients at risk and often the work falls to the nurses who are familiar with the patient population or the equipment. At this point the additional staff many times is not helpful but really just more work to either explain or do the cares for that nurse who doesn’t know how to perform the task, work the equipment or deal with the patients.
  • Unqualified staff-wrong skill mix. The wrong skill mix was sent to the unit to help, either a LPN or CNA may have been sent to fill a RN shift, or another RN was sent when 2 CNA’s were needed maybe for 1:1 sitter assignments, sitting in a patient’s room because the patient is at risk for falls.


Patient Story

arlene townsend staffing award

Unsafe staffing costs a Florida facility $1 billion

From Trial Magazine, March 2014 issue: Trial Magazine, 3/11/14 VERDICTS & SETTLEMENTS Arlene Townsend, 63 suffered a stroke and required 24-hour care. She was admitted to Auburndale Oaks Healthcare Center, a nursing home owned by Trans Healthcare, Inc. In the three years leading up to her death, Townsend suffered numerous fall resulting in broken bones and lacerations, infections, significant weight loss, chronic constipation, skin breakdowns, dehydration, and other problems. She is survived by her adult son. Townsend’s estate sued Trans Healthcare, alleging that it had understaffed the nursing home to increase profits and failed to provide adequate care, including protecting Townsend from falls, ensuring a safe environment, and documenting changes to her condition. The court entered a judgment of liability against the defendant, and the…
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