I’ve seen medical directors who wouldn’t come to see their patients regularly.  I’ve seen them fail to keep their progress notes up.  I’ve seen medical directors dictate what home health  or hospice company a nursing home would utilize.  I’ve seen medical directors who wouldn’t “let” their facility use any other type of negative pressure pump other than KCI, even when KCI was overcharging.  I’ve seen medical directors who would not culture wounds because they didn’t want to know if MRSA was present, and then, obviously, failed to order the appropriate antibiotic treatment.  Some failed to attend the QA Committee meetings as they are required to.  I have even seen medical directors who hindered the admissions process at facilities demanding that all referrals be run through them before the facility accepts or they wouldn’t take the patient.

All of this is unacceptable.

The way I look at it is this – I pay the medical director.  He is a contract employee of mine.  He works for me, not the other way around.  He is certainly not going to stand in my way or hinder my progress.  When I take a facility, I usually ensure the medical director knows what direction I will take the facility right from the start and I make sure he understands that we need to be on the same team to accomplish this.  I’m not confrontational, but I make sure he understands that I’m a professional and that I am the leader of my facility; I’m not the complacent, stay-in-the-office, never-say-anything administrator that he may be used to from the past .  If he is unwilling to get on board, then he probably should have never been hired in the first place.  Many times, a physician is hired as the medical director without giving much thought of how they will impact the facility.  I have hired and fired medical directors and have had to have many conversations to ensure they were taking care of what I expected them to.  If you have hired or inherited a medical director who is failing to live up to your expectations after you’ve had the necessary conversations with him, cut your losses.  Can him!  Don’t worry about how it’s going to affect you in the community.  You can’t be held hostage by a physician who isn’t vested in your success.

I always have the cell phone number to the medical director and they are accessible to me 24/7.  I have no qualms about calling them on a Saturday to deal with a problem they failed to address Friday.  On the same note, it is an unwritten rule that if you are the medical director, you will accept any new patients that we don’t have another physician for.  If you can’t handle that, I doubt you can handle the other expectations I have of you.

Administrators, it’s time to toughen up.  Don’t let your contract employee (aka medical director) run over you.  Set your team up for success by hiring the right physician and ensuring excellent communication with them.  Take control of your facilities, set the example, and be a leader.  Physicians have to be managed, too. You’re the person responsible for doing it.

Good luck!

We’ll highlight several areas in your facility that may or may not be included in your monthly debriefing.  This is definitely not all-inclusive but should give you a great start and have you asking many of the the right questions.  These conference calls generally review the previous month’s financial outcomes and current/future census projections.

Depending on your company’s set-up, you may desire to have several of your department heads attend the call as well.  You want to have them in the same room as yourself on the same phoneline.  You should have prepared them several days prior to this call so they can modify their schedules to make sure they are present and prepared.  I generally let the responsible department head answer questions about their own department.  The Marketing or Admissions Director answers census questions, the DON answers clinical, and so on.

For any negative variances to budget, you’ll need to put together an action plan that details an explanation of the problem, what you’re doing to fix it or get it in-line year-to-date,  who’ll be responsible for what actions, how it’s going to be reviewed, and when it will be fixed.

1.  Census

You’ve absolutely got to know your census everyday throughout the day.  You should know the total census as well as census mix by payer type compared to budget for the prior month and current month-to-date.

How many admissions have you had this month?  How many clinical denials?  Did these denials go through the proper channels?  Same for financial denials.

Were there any prior period days adjustments and, if so, what for?

How many Private Pay do you have?  Who hasn’t payed for the current month?

What is you hospital discharge %?

What is your projected ending census for this week? If below budget, what actions are you taking?  What new marketing opportunities exist?

2.  Revenue Rates

Private Pay fluctuations from last month?  Why? 

Does your Hospice rate match your Medicaid rate?

Insurance/Managed Care/HMO – what does the contract say for each of these residents?  Is it negotiated rate, per diem, or RUGs-based?  How much rehab does the contract allow?

Average Part A rate?

What is your Medicare length-of-stay?

Did you have any default days and why?

Medicaid – questions would depend on if your state is casemix or not.

Part B volume?  What % of Part B eligibles are on therapy caseload?

3.  Ancillary / Rehab

Any changes in your ancillary rates from last month?

Any ancillaries you’re paying for that should be covered under Hospice, Insurance, Medicaid, etc?

Is Therapy in-house?  If so, what was their productivity?

If contract, did they meet the terms of their contract?  Any wasted minutes? Or did they miss any RUG levels?  Did you review the invoice?

4. EBITDARM, EBITDA, or Net Profit

Your company may focus on different lines on the financials here.  EBITDARM means earnings before interest, taxes, depreciation, amortization, rent and management fees.  Net profit or net earnings is your total expenses subtracted from your gross revenue.  Typically, what you need to know is did you make budget based on the bottom line your company is looking at.  You have controllable and uncontrollable expenses, but keep in mind, even if an expense is uncontrollable, you are expected to compensate in other areas to ensure a favorable net profit outcome.

You’ll also need to know where you are year-to-date and what you’re doing to “catch up” if YTD you’re behind budget.

5.  Labor

What were your labor PPD’s and payroll expenses for the review period? Total and per department?  Are you at budget?  Will you be at budget on the next labor report?

What was your overtime % for the period?  Was the OT approved or pre-authorized?  Why?

What are your open positions? (Note:  It will be very hard to explain why you are running OT if you have no open positions – that’s why you should watch your labor daily).

Turnover%?  Who was terminated in the last review period and what happened? Terms in 1st 90 days?

Any premium pay or bonuses?  What for?

Any agency staff used?  Why and what measures are you taking to eliminate? (Agency is very expensive to run.)

6.  Controllable expenses

You will go line-by-line and review any controllables out of budget.  Some companies go strictly by PPDs; some go by anything $100 over budget or $500 over budget.  You should review your financials several days prior to the call and have researched the GL accounts thoroughly in order to be able to answer the questions you’ll get.

How often are you reviewing department spend-downs?

How are your controllables YTD?

A sample of general controllable expenses may include:

• Nursing supplies
• Incontinence supplies
• Activity supplies
• Raw food expense
• Dietary supplies
• Food supplements
• Laundry supplies
• Linen
• Housekeeping supplies
• Maintenance & Repair expenses
• Minor equipment expense
• Office supplies
• Postage
• Marketing expenses
• Bad debt (discussed below)

7.  Bad debt

What is the status of your delinquent accounts?

Howmany Medicaid-pending do you have?  How long have they been pending?

Any no-payers?  Have you sent any discharge letters?

What is your current DSO?

Any barriers for collections?

Review any over $10 k accounts.

8. Ancillary expenses

Typical ancillary expenses may include:

• Rehab supplies
• Central supplies
• Equipment rentals
• Complex Medical
• Pharmacy
• Medical Supplies / oxygen supplies
• Lab, X-ray
• Physical, Occupational, Speech Therapy expense
• IV and Nutritional therapy
• Medical Services, Transportation
• Misc.

Pre-authorizing any Medicaid rehab?  (Medicaid does not pay for rehab in most states).

Are you verifying rehab isn’t exceeding insurance authorizations?

What equipment are you renting? How long have you been renting it and is it still needed?  Do we need to purchase?

Any large variances in pharmacy costs month-to-month?

Did you review the pharmacy bill for accuracy as well as to identify high-cost drugs?

How many tubefeeders?  Payer source?

Fluctuations in lab, x-ray, transportation costs?

9.  Workers comp

Any open workers comp claims?  Status?

Anyone on modified duty?

10. Other expenses

Are expenses being accrued appropriately?

Any consultant expenses?  What for?

Any building contracts, grounds , maintenance?

Education & training?

Orientation

Utilities

G&A expenses

11.  Clinical

Depending on your company, this could be a whole other call and, many times, it will be weekly.  Typically, you’ll review this at the minimum:

# Flags on QI/QM

MDS Transmission, late assessments

Falls, falls w/ injury

Wounds – pressure and non-pressure, facility-acquired or no-facility-acquired

Restraints

Weightloss

Unplanned hospital discharges

Any action plans for Nurse Consultant visits or survey POC

12. Survey activity or Plan of Correction progress

Complaints, any self-reports, annual survey

I’d like to discuss one particular type of referral that I believe you should always think twice about before admitting.  I’m not saying don’t admit.  I’m saying you should carefully consider the consequences.  The type of referral is this:  The family member of a current employee.

“What?!” you say!  These are the best kind, right?  I mean, the employee already knows what to expect.  They won’t have unrealistic expectations, right?  Not so fast.  Actually, many times the employee may assume that the other staff will do an even better job because it’s their mom or dad.  What happens when the employee (who is a good employee, by the way) becomes dissatisfied with the care their loved one is receiving?  This can happen with any family member, right?  What happens is the employee can begin to lose faith in the facility, the staff, and the management.  They become resentful.  They are afraid if they speak up too much they’ll lose their job but if they don’t say anything, their loved one will suffer.  Sometimes, they even begin to call complaints in to the State themselves when they can’t get the results they expect at the facility level.

You can handle all those things you say?  Ok, what happens if the employee isn’t such a good employee and they have to be disciplined for their job performance?  At this point is when you start receiving care complaints on their family member.  That’s pretty much guaranteed.  Even worse, what if you have allegations of abuse against the employee?  What if you substantiate the allegations?  You still have their family member there as a resident.  What are you going to do when they want to visit the resident?

On the flip side, many times, you can have a great experience with the referrals generated from your employees and can reinforce their trust in you if you do a good job with their family member.  Employees are definitely a source for referrals, I just want you to carefully consider each one before agreeing to admit. 

Thanks for reading today!

I bought this picture to remind me that other people go through the same trials and experience the same feelings of hopelessness.  Sometimes, it’s not about winning; it’s about persevering – outlasting your opponents.  I would look at the picture and it did seem to help me get refocused and realize, “Hey.  I’m still here fighting.”

Anyway, it’s motivational to me and I find it amazing ole Abe didn’t quit.  Here’s the text on the picture highlighting his life and career failures along the way to becoming President:

Failed in business in 1831.

Defeated for Legislature in 1832.

Second failure in business in 1833.

Suffered nervous breakdown in 1836.

Defeated for Speaker in 1838.

Defeated for Elector in 1840.

Defeated for Congress in 1843.

Defeated for Congress in 1848.

Defeated for Senate in 1855.

Defeated for Vice President in 1856.

Defeated for Senate in 1858.

Elected President in 1860.

Talk about a tough road!  He simply persevered.  And he finally found success.  Remember that the path to success is full of failures.  Just don’t give up.

The BASICS MEMO was compiled after having to troubleshoot many facilities and seeing the same common issues cropping up or the same survey deficiencies being cited over the same problems.  It all boiled down to not following the basic standards of long term care.

The BASICS MEMO (which is most likely the longest memo you’ll ever receive with 115 clearly communicated standards of expectation outlined) clearly identifies exactly what I expect from my staff members on a daily basis – the minimum requirements.  I wrote it in an easy-to-understand form so that there’s no miscommunication.  I would go so far as to say that taking the basic standards that I want to see in place everyday, putting them in a format the staff can understand, and making every staff member knowledgeable and accountable for them is the most important element of my success in the past 10 years.  It is absolutely critical that you communicate to your staff what is expected of them and back it up in writing.

The contents of the BASICS MEMO are not new concepts.  These are the basics that should have been in place since Day 1.  Oddly enough, most of these basics are not usually found in your facility’s policy and procedure manuals.  They’re not usually found on job descriptions.  These are things we expect our staff to know, but we hardly ever teach.  I remedied that.  I no longer just assume that my staff know the basics.  I ensure they do.

I’ve used the BASICS MEMO in turnaround situations with facilities suffering from disastrous surveys, to facilities with years of mismanagement, to facilities that ran smoothly and just needed someone to hang their Administrator license.  It doesn’t matter.  It works for all nursing homes and has information every employee needs to hear.  I typically make copies for everyone and then put a copy by the timeclock for good measure.  If I walk into a room and see double-padding on a bed, I simply ask the CNA and nurse if they read my BASICS MEMO.  Knowing they did as this was my first assignment to my staff, there really is no excuse they can give me for being noncompliant. It takes away the excuses.  ”I didn’t know…” no longer applies.

I encourage you to do the same – take away the excuses.  Give your staff a tool that lets them know plainly in black and white exactly what you want to see everyday on your halls.  If your staff members follow the BASICS MEMO, if they put the BASICS in place – you’ll have a great survey!

How To Get Your Free Copy:

To claim your free copy of the BASICS Memo, simply register in the GET YOUR FREE BASICS MEMO HERE Box in the right sidebar.  This is the same document I use daily in my facilities.  Feel free to edit and customize it for use in your facility as well.

Once implemented, I’d love to hear how well it helped you!

"Won't you protect me?"

Today, we’ll talk about hypersexuality of the nursing home resident when there is no 2 –party consent for sexual advances, and what to do to manage this behavior.

In the nursing home industry, you’ll run across it sooner or later.  A little male resident who goes from female resident to female resident attempting to touch, kiss, and grope them inappropriately.  He disrobes in public… or worse.  He tries to go into their rooms.  He is sneaky and waits until staff are busy and no one is visible in the area.  He preys on the most vulnerable of our residents – the ones who are confused, demented, and who usually can’t report the incident.  He may also get brave and begin this behavior with your staff as they are attempting to shower or dress the resident.  This can set you up for worlds of trouble.

What we must do is stop the inappropriate behavior and safeguard our residents as well as our staff.  There is no sweeping this under the rug hoping it will go away!

If not, not only do we put our residents and staff at risk for sexual abuse, you almost definitely set yourself and your facility up for an immediate jeopardy tag(s).

You need to evaluate the initial inappropriate behavior by the resident and address it immediately.  If not, it only gets worse.  Some residents start off with trying to grope the CNAs.  You must educate your CNAs to report this sexual aggression and you must take interventions at that time.

We have to attempt to find the source of the behavior.  Is there a new medication the resident is taking?  Is it related to the patient’s dementia?  Is there a history of sexual abuse or sexual inappropriate behavior? Is there a UTI or psychiatric disorder?  Does the resident have delusions?

Is it actually sexual behavior?  For example, removing clothes or inappropriately touching the staff when hugged or assisted with baths may not necessarily be sexual aggression.  It could be disorientation or confusion on what is actually going on related to their dementia.  If the resident has targeted one specific female, it may very well be likely that he is confusing that resident/staff member with a spouse or significant other.

Obviously, we would attempt non-pharmocological interventions at first to redirect the resident but we’d also consider a medication regimen if unsuccessful.  Collaboration with appropriate mental health professionals can produce excellent non-pharmocological interventions.

A cognitive screen and lab work-ups should be completed for the resident.  Labs may include a blood glucose level, BUN, CBC, PSA, LH, Testosterone level, urinalysis, and liver function.  For aggressive hypersexualism, you should make use of your resources.  Keep your primary physician and medical director in the know.  Bring in your pharmacy consultant for medication review.  Bring in mental health professionals for geri-psyche as appropriate.  Room changes, frequent or even temporary 1-to-1 monitoring may be necessary to manage the behavior.  The family should be kept in the loop and they’re also a source for historical information on the resident to see if these behaviors have occurred in the past.  Staff education is a necessity and must be ongoing.

No medication, as far as I know, is currently approved for the treatment of sexually inappropriate behavior.  That being said, there are a number of medications that are commonly used for the purpose of managing these behaviors (or at least allowing the drug’s side effects to kick in effectively reducing sexual desire).  Let me tell you, it is usually a game of trial and error.  The local primary physician may not be well-versed with hypersexuality in long term care, so it is of utmost importance to make sure they are discussing options with your pharmacist and mental health provider.  Many times, it may take a combination drug therapy approach to effectively reduce or eliminate the undesirable behavior.

Common types of drugs used for the management of hypersexuality and sexual inappropriate behaviors in the long term care setting:

• Chols (cholinesterase inhibitors) – may decrease libido, may help cognitive and behavioral issues – examples –  Aricept, Exelon, Razadyne
• SSRIs – may decrease libido and offer better impulse control – Celexa, Paxil, Zoloft, Prozac, Androcur
• Mood Stabilizers and Antipsychotics – (limited usefulness) may help calm aggressive behaviors – Risperdal, Lithium, Depakote
• Antiandrogen agents – may decrease sexual aggression and misbehavior in men as well as decrease fantasies and urges – Provera, Depo-Provera
• Leuprolide/LHRH agonists – may inhibit gonadotropin release and suppress testosterone production – Lupron, Zoladex
• Estradiol – may increase estrogen levels and decrease sexual behavior.
• Cimetidine (Tagamet) – may decrease hypersexual behaviors.

I am not a physician, nor a pharmacist.  I am not advising you to use any of the drugs listed above for your residents or for the treatment of any disease or condition.  However, one needs to know what options are available when attempting to manage the sexually inappropriate and sexually aggressive  resident in the LTC setting.

Every drug has side effects that must be monitored and many of the ones listed must have labs ordered with them.  Depo-Provera is a great drug for use with these behaviors, but I have seen residents swell after a few months on it.  There are also ethical considerations of altering the balance of a resident’s hormones for the purpose of behavior management.  Choose wisely, keep the family and physician in close conversation.  Update the care plans and monitor the resident closely for effectiveness of the drug as an intervention and for potential drug side effects.

Even with a combination of these drugs in place, it still may be impossible to manage the resident’s hypersexual behavior.  Don’t be afraid to utilize a short-stay geri-psyche facility or to discharge the resident altogether (to a safe environment).  I would much rather take a tag on inappropriate discharge than an IJ on sexual abuse in the facility.

I would love to hear your opinion on this and if you’ve had success with other measures.

You’ve done your background checks, screenings, and interview and have selected a new caregiver to start training in your assisted living facility. Although you’ve done everything in your power to setup a good training program and select a good caregiver candidate, there are 4 common problems that can come up and bring havoc to the caregiver’s training. These four problems include: Information overload, lack of a mentor, an area a caregiver just can get right, and lack of information reiteration.

The first problem we commonly see come up during training is information overload. Caregivers have a lot of responsibilities. Often times, they cook, clean, run errands, and provide social activities for residents. When a caregiver first arrives at your assisted living facility for training, they can become bogged down with too much information. This often leads to them forgetting simple tasks that need to be done, and their training not being as complete as it should be. The simply solution for this is to spread your caregiver’s training out over the course of a long period of time. Each day is set a side for a new skill or process the caregiver must learn.

The second problem we often see is the lack of a mentor. Anybody in a new job position needs a mentor, someone who has been there longer and knows the ropes. Not having a mentor leads to them making mistakes that could easily have been avoided. The simple solution for this is to allow your new caregiver a day or two to “job shadow” an experienced caregiver.

The third issue is that we often get a new caregiver who just can’t quite get one area of their job right. As we already mentioned, caregivers have a lot of tasks that are expected of them. There might be one or two they are not proficient at. The way around this is to devote extra time for their training in that area, and have them train with one of your staff who are very good in the area.

The final common problem is lack of information reiteration. It is said that humans need to hear something at least 10 times til they understand it. If that is the case, then caregivers must be showed something multiple times. The best way to do this is ask them multiple questions on the same topic throughout their training.

Caregiver training can be a tough process. To get more tips on elderly care, be sure to visit Adult Family Home.

Thanks,

Daniel

At one particularly confused facility, I had two residents who had developed a fondness for each other and seemed to want alone time together.  At least that’s what the male resident who could make his own decisions said, even though his family was mortified at Dad doing that kind of thing.  His chosen mate, unfortunately, could not make decisions very well and was frequently confused.  When I inherited this facility, I found out the staff had been allowing the residents to have sex per the direction of the Ombudsman (who was watching out for those residents’ rights! ) and the confused female resident’s daughter who stated, “My Momma can have sex if she wants to…”

Hit the brakes!  Oh, no she can’t!  Not in my building if she can’t give consent.  Finding out this little bit of information gave me a headache and a few heart palpitations.  Let’s go through a couple of points to consider here.

1. The major determining factor of whether to allow these two residents to have sexual interaction lies with the ability of both residents to give consent.
2. It doesn’t matter whether the confused female’s daughter has a POA, guardianship, conservatorship, or anything else.  The resident is in the care of the nursing home.  True – when a resident is unable to make their own decisions, the resident’s rights are transferred to the Responsible Party or to an individual directed by a court.  However, this does not include the ability to violate their human rights.  Human rights remain with the resident.  A responsible party cannot direct for a resident to have sexual intercourse or be subjected to any form of such interaction any more than they can direct for the resident to receive a high dose of insulin when the resident is not even diabetic.
3. An Ombudsman has no authority to direct anything in this situation.  (This was a particularly bad Ombudsman).  However, if the Ombudsman feels like the resident’s rights are being violated, they must report this to the State.  So, you need a protocol in place to shut down any potential deficiencies.

First and foremost, you should have some type of sexuality assessment tool in place to determine the resident’s ability to give consent.  Here is a generic one (click here) that borrows a bit from Lichtenberg & Strzepek, 1990, Lichtenberg, 1997, and an old Pro-Ed form I got from a colleague in 2001.  Feel free to modify and individualize it for your own facility.

As you can see, there are many points to consider in order to make a determination of the ability to give consent. Use an assessment.  Review the results with the IDT team, family, and physician.  There may need to be some ongoing education and reminders for the resident to ensure their continued understanding and safety.  Or, they simply may not pass at all.  Update the care plan with the sexuality assessment and ongoing plan.

I had a female resident at one facility whose former profession was prostitution.  She was moderately confused at times, but still had enough about her to select a male suitor to fancy.  The problem, other than her unpredictable state of mind, was that she had syphilis.  And, the particular resident she selected to be her fellow had HIV.  What a bad combination.  Of course, neither knew about the other’s condition and I couldn’t tell them due to HIPAA.  So, I had to develop a sexuality assessment for the facility which included risk of STDs.  He passed fine.  She didn’t.  I then had a long talk with both residents individually.  In my conversation with the male resident, I might have thrown in a few hypothetical situations that would help persuade a man not to pursue a woman.    Right or wrong, it worked.  He stayed his distance from her and we didn’t have any problems.

Stay tuned for Part 2 where we’ll discuss behavior management for aggressive hypersexual residents when there is no consent for sexual interaction.

You want to accomplish great things in this long term care industry we call home.  Here are 10 points to consider.  If you’re doing any of  these, it could very well be the roadblock on your highway to success.

1.  Not Putting Care First: Your number one priority everyday, day in and out, should be the care of your residents.  There should be no waffling over whether to pay all that money to rent an air mattress for your resident who was admitted with serious wounds.  Put the care first and mark this sin off your list.

2.  Failing to Make Rounds:  I hate being an “office administrator.”  Granted, there are many responsibilities, conference calls, reports, phone calls, and emails that tie you to an office, but the successful administrator makes time to get out and about checking residents and rooms, and interacting with frontline staff members.  Otherwise, how do you really know what’s going on out there.

3.  Failing to Build a Functional and Cohesive Team: If you have negative team members, they will destroy the progress you’re trying to make.  Team members who are always complaining, always ready to criticize others, always finding the faults or weaknesses of any task or project you’re working on – well, these people are a disease.  They have to go.

4.  Lack of Emotional Control: I’ve said it before, if you can’t manage your emotions, you can’t be your most successful.  Lack of emotional control leads to bad decisions, stress, and team breakdown.  We’ve got to grow up and get it together.

5.  Financial Incompetence: Know your financials.  Know how they work.  What expenses hit what GL (general ledger) accounts.  Cost out risky referrals.  Eliminate unnecessary overtime.  Make sure people work their schedule.  Keep department expense budgets in line.  Push Medicare and Managed Care.  Collect your money.  Adjust your staffing to in-house census.

6.  Not Knowing Your Regs: Your watermelon book is your key to survival in a survey as well as in your daily operations.  You have to know the regs to know how to react to situations that arise.

7.  Over-promising to Family Members: Your staff will love you for this one! (Sarcasm). A lesson that should be learned from Day 1 is under-promise and over-deliver.  When a family member comes to rip you a new one because they found their mother wet, the best response isn’t, “It will never happen again!”  Because it will happen again.  Because the resident is incontinent.  Because the staff find her wet 12 times a day and the family just found her this time before we did.  It will happen again.  The best answer in situations like this is:

• Letting them know that you’re sorry they found her that way.
• Being realistic since she is incontinent, telling them that you can’t promise they’ll never find her like that again, but that you can promise as soon as you’re aware of it that your staff will get her taken care of.  They shouldn’t find her like that daily, obviously.
• Explore what options are available – scheduled toileting program?  More frequent incontinence checks?  Anything going on clinically that can be addressed and is contributing to the incontinence?

8.  Failure to Support and Drive Facility Marketing Programs:  Many old-school administrators just don’t get this one.  They operated in a different environment with less competition and a less savvy consumer.  Nowadays, make no mistake – you are in fierce competition for your referrals!  Marketing is just as important as any other aspect of the nursing home business.  Without proper marketing, your facility loses community recognition, referrals decline, and soon, your census suffers which in turn affects revenue.  With lower revenue, you have to make it up somewhere, so expenses are cut and then you are running less staff, you can’t purchase needed equipment, your supplies budgets are affected, and a vicious cycle begins.

9.  Failure to Give Positive Reinforcement: Your staff need it.  If your making rounds as we talked about in #2, you have the perfect opportunity to catch people doing something right.  Let’s get started.  Your staff morale will benefit greatly.

10. Trying to Manage Your Friends: Many times, insecure administrators, in an effort to “fit in”, make friends with their employees, their direct reports – hanging out with them after work and the like.  I’m not saying that it’s necessarily wrong to make friends at work.  I’m saying it’s difficult to manage friends and you shouldn’t put yourself in that position.  You have to make a decision.  Are these people friends or employees first?  What happens when one of them does something that needs to be addressed or requires disciplinary action?  Most people will avoid addressing the issue.  Meanwhile, the rest of your facility staff are watching to see what you’re going to do.  ”Playing favorites” has no place in our facilities and can be destructive to your team-building efforts.  Your staff will lose respect for you if they see you playing favorites and then you’ve lost control of your facility.  Instead of being buddy-buddy with subordinates, just be respectful, consistent, and supportive.  Draw some lines between your personal life and your work.

There you have it – the 10 Deadly Sins of the Nursing Home Administrator.  Now that you can recognize them, you will be able to avoid these pitfalls and keep yourself on the path to becoming a great administrator!

Tell me what you think and let me know if there’s anymore “sins” you’d like to see added to the list.

Thanks!

That’s fine.  They simply need to manage their hours to avoid unnecessary and unapproved overtime.  However, one of the Nurse Admin team members ended up having to work the floor in a charge nurse slot to fill a hole in the schedule.  She ran into 2 hours overtime due to this. 

The administrator lost it!  Not having any emotional control, he decided to change the whole pay system for all of these people.  It created chaos and  upset a lot of individuals.  All the Nurse Administration team went to salaried exempt positions that did not receive overtime compensation.  He neglected to write new policies on what happens to the their benefits, i.e. paid days off which is different for salaried than it is for hourly.  He neglected to check with the labor board for clarification on several issues which leads to me having to clean it up.

Actually, I see this a lot.  I see entire companies change the way they’re doing things, change systems, due to employee problems.  Why not just address the root issue?  If the employee is at fault, don’t change the system, address the employee.  If there is a scheduling snafu, don’t change the system as a first response.  Look and see what happened.  Otherwise, you could be creating more problems for yourself.

Knee-jerk reactions like the one described above usually do little to fix the actual problem and often create other problems to boot.  As a leader and decsion-maker, we must get our emotions in check, manage issues as they arrise, and think about the best possible solution that addresses the root cause of the problem.  The answer is not always to tear down a system.  It’s more often to do the uncomfortable and address someone that needs to be talked to or shown a different way of doing their job.