Tuesday, August 13, 2013

How to Manage A Toxic Assignment

Back to my blog home page: http://travelingotr.blogspot.com

It's been a smooth ride since my first travel assignment in August 2009. I'm happy to reminisce on great work environments, coworkers who have become dear friends since then, and interesting places I've been...it's been so very life changing!

Last month, I moved from California to Washington. I absolutely love Washington, and I know I would like to stay for a while to explore such a diverse place. It provides a perfect landscape for my love of hiking, biking and living near water and mountains.

My first Washington assignment, though, was less than stellar.

I was in a building that looked beautiful, had the largest and most well stocked rehab gym I've been in for years, and happened to be

SNFs (skilled nursing facilities) are not always what they look like. I've been in some that look shabby but that provide the finest care around.

This SNF was in stop placement.

That means they were not allowed to admit any new patients,
which happens when a building is in trouble with the state.

In my first six work days at the new place, I was tested on abuse/neglect, attended an in-service on abuse/neglect, and an employee from a sister facility went around the building quizzing employees how to answer state surveyor questions about....

you got it...

abuse and neglect.

What the heck happened there?
I never sat down and read the results of their latest survey. Within two days, I was working with my recruiter and clinical liaison to get out of the contract. It was difficult to find more than a handful of people who had worked here longer than a month or two. Really, in 17 years, I had never seen anything like it.
This was one of those times I was glad that I was not a new grad traveler, which would be absolutely frightening. I can't go into further details except to say that this was one of those places in which I was seeing situations that make me uneasy...I didn't see abuse or neglect, but I just wasn't seeing the level of commitment to caring for others that I have experienced in past assignments.  In addition, the rehab director was not only absent, she was...clueless. I hate to say it, but again....I have never seen anything like it.
Today's blog is about recommendations for how to handle a toxic assignment. This is not how I function on a daily basis. Usually, it is so very easy to provide great therapy and to communicate with a healthy, proactive nursing and social work team. This advice is for dysfunctional buildings.
 Rule #1: CYA
Hyper-vigilance is sometimes called for. Be aware of every word you say.
Do not offer any information other than what is asked of you. Cross every "t" and dot every "i." Document everything you notice about your patient, especially any new bruising, behaviors, or conditions. For example, I found the same patient soaking wet every mid-morning for several days. Unsurprisingly, she also had a UTI - and so did several others on her hallway.
Rule #2: Explain
Explain what you plan to do with every patient/resident prior to treating. In some cases, you may need to explain to someone else, like a family member or a state surveyor who is watching or questioning you.
Educate other staff members, nurse aides or nurses and document your education sessions. (You should be doing this anyway!)
Rule #3: Know "best practice"
If you are asked to evaluate a patient and there is no skilled documented in the chart to justify the referral, educate the nursing staff about what documentation you need. Communicate with the Director of Rehab that the referral lacks clinical justification. A screen from rehab does not justify treatment. It looks simply like a self referral. The DOR in this troubled building actually stated to me that "a screen form from the PT justifies evaluation" with no other documentation in the chart to support the referral. The poor PT was new to practice in the United States and was unaware of best practices.
Rule #4:  Identify a support system
If your manager is not physically there to support you and your team, seek support with the members of the team and identify the strong players on the team or people who know the history of the building, the staff and the residents.  
Rule #5: Communicate with team members
If there is no rehab department leadership or regular rehab meeting to coordinate patient discussion between the therapies, initiate a time with the other therapists to do proper discharge planning.   
Rule #6: Know what you're dealing with in the building
Get a copy of the HCFA 802 from the MDS coordinator
so you can see who the building has identified with which Quality Indicators, which may include pain, pressure sores, UTIs, falls, behaviors, declines in ADLs or ROM, swallow, or weight loss.
HCFA 802 (example to the right)

Rule #7: Follow your gut
 If you have a queasy feeling in your stomach about working in the building, start making a list about the things that make you uneasy. Call your recruiter - and talk with the clinical liaison from your company. Don't cry wolf over small things. Make sure your concerns are founded on valid concerns.

In my case, the travel PT and I called the clinical liaison together. We also left the contract on the same day, which happened to occur the day the state walked into the building.

We are all mandated reporters. The state was aware of our issues. They were already addressing them.

Rule #8: Don't be afraid or embarrassed to leave an assignment early if you know it's the right thing to do.

It should rarely happen. I am still surprised it happened after such a lovely flow of assignments. I am, however, relieved and ecstatic to be away from such a negative place.
I hope that you don't have this experience as a traveler.
If you do, don't hesitate to contact me.
Maybe I can help you through it.

1 comment:

  1. As a new grad, I benefited from this post, thank you!!