Getting Paid for Every Minute You Work

About being paid for the hours we work…this is an article about the LTC industry and Fair Labor Standards Act (FLSA or the “Act”):

Another minefield, as simple as it may seem to navigate, is tracking and counting “hours worked” to determine if overtime pay is due. The key words are “compensable hours,” and hours can be considered compensable even if they are not scheduled or authorized beforehand or approved after the fact if they are indeed “worked” by the employee. The time is worked for purposes of the FLSA if the employer “suffers” or “permits” it to be worked. That is, if the employer, or one of its “agents” for this purpose (head nurse, unit coordinator, department head or, for that matter, any supervisor), knows or reasonably should know that the employee has performed work, it must be counted. Rank-and-file employees should be instructed that any time they are performing work, it is “on the clock.” Supervisors must be trained to, among many other things under the FLSA, recognize that any time an employee is performing job-related tasks, be it before or after the start or end of a shift, during lunch or other unpaid breaks, or even at home, he/she must ensure that the time is included in compensable hours for overtime calculation purposes. If the supervisor “suffers” or “permits” the employee to work, it is counted toward the overtime threshold.

THIS means, simply, that if you work, you get paid irregardless of whether the DON or other supervisor “approved” the hours. Often I read at the forums that we’re not paid because the time wasn’t approved by the boss. Legally, we have to get paid.

Employers must also become familiar with what job-related activities are considered compensable activities and which are not. For example, requiring an employee to change into a uniform at the worksite is compensable, while worksite clothes-changing for employee convenience is not. Pre-shift distribution of work or assignments and, by all means, shift change meetings or “report” are compensable, as are simple things like having an employee pick up or drop off mail or packages on the way from/to home or during lunch. Performance of work during unpaid lunch periods is particularly troublesome—a huge minefield—for healthcare employers. Regulations require that the lunch break be “uninterrupted” and be at least 30 minutes for the employer to exclude it from time worked. It is not uncommon for LTC employees to eat at their workstations or with residents, and it is also not uncommon for caregivers to be called or be called back during lunch break to deal with resident issues. All of these are problematic. If the employee’s lunch break is interrupted—he/she performs any work—the entire break becomes compensable time in determining if overtime pay is due.

So…remember this when you’re on your break and get called to the unit. Check your pay stubs to make sure you’ve been paid. It helps to keep a personal log of the hours you work…a little notebook will suffice for this purpose. The date, time clocked in, out, breaks (especially) taken and clocking in/out AND, importantly, going back to the unit. I think it’s safe to say a great many of us get screwed over often, in pay because of these “little” things. We work hard and we often miss our breaks. Let’s get paid what we’re due.

Question of The Week: Falls and Responsibility

Question:
At work today I got into trouble because one of my residents' fell. This man is independent and never needs our help. He can do his own care- showers, dressing, walking, meals, toileting...the works. As far as I know he has never fallen before. I was busy with one of my other residents who requires total cares. I was in the middle of bathing her when the nurse came in to tell me the man fell and why wasn't I with him? After I finished up with my lady's care, I was told to fill out a report which wanted to know what I COULD HAVE DONE to prevent the fall; THE LAST TIME RESIDENT WAS TOILETED; THE LAST MEAL consumed- all things that had nothing to do with this fall!!

Later, I was written up for the fall. I told the DON that everyone is responsible for ALL the residents on the hall I was working. Yes, he was assigned to me, but when I am busy with other residents, my co workers should step up and cover for me. What do you think of this?

Answer:
You should not have been written up, in my opinion.

Every resident must be assigned to a CNA. It's law. No way out of that. Every aide accepts their assignment and therefore responsibility for the residents on it. Each CNA is responsible for her assigned residents and the unit, as a whole, cannot do this.

It's tough when bad things happen to good aides, though.

Did you read the man's care plan? Are you absolutely sure he is independent in his cares? If so, did you check in with him to see if he needed any help, with anything? I think sometimes we assume these residents who are able to do their own care never need ANY help- and this isn't always the case. When doing this check in, it's always a good to ask when they're planning to get up; what they're bathing plans are and the like. This way, you can have some awareness that Mr. Smith is going to be up and about around 9am, and might need someone to just peek at him.

Of course this is where team work comes into the picture. Every time an aide is going to be tied up for awhile with residents, its always a GOOD thing to let as many peers know where you're at. And include the nurse with this info as well. If you're so inclined (and I would be) I would ask peers to keep an eye and ear out for your other residents...especially if I was going to be tied up for a longer period than usual with the other resident. A good charge nurse would make sure your other residents are covered as well. It's a balancing act though: Asking every aide to cover the others' residents every time personal care is being performed is just not practical.

As for the report: It's called an Incident Report. The questions asked do indeed have everything to do with the assessment of a fall. By asking you what you could have done to prevent this fall, the answers you provide are supposed to be helpful to prevent a repeat in the future.

Did you know most residents fall because they are trying to get to the bathroom? If they're hungry they might be trying to rush out to a meal. Usually there are other questions too on these reports- about all sorts of things. Often we don't know the prior condition of any resident when they have fallen without a witness.

It's very important for CNA's to answer these things honestly...however....when we're written up it takes away the desire for CNA's to have any respect for these reports. These things should never be used as a means for punishment. When independent residents fall, it is NOT the direct fault of the aides. It was caused by something else. It IS up to management to figure out why the fall occurred- but by placing blame on the aides they are short changing this process. This is another example of autocratic management style- which isn't helpful. And, I have to wonder if nursing homes with high fall rates have these kinds of managers.

I'm sorry you got written up. Of all the things CNA's don't have control over, the FALL tops the list. The work loads alone should tell all that it's impossible to be everywhere at the same time- or even once an hour. A good fall prevention program begins with a trusting environment where no one is disciplined for falls unseen. Once that is in place, true prevention strategies can be developed AND the CNA's are the most valuable asset to this process.

CNA's And Respect

CNA’s and respect

In the LTC setting it seems that one of the most important skills we all should have is in severe lacking: RESPECT. Respect towards our peers, leaders, people who work in other departments and residents. Without a healthy amount of respect towards others we close doors upon ourselves.

Respect towards peers- other aides- is SO important if one wants to able to work effectively and in a team like manner. It isn’t hard to respect others, it just seems so. First, we have to let go of all our old assumptions about people. Start with a fresh perspective and it is easy.

People generally:
Like to be helpful
Like to be liked
Like assistance
Like “fitting” in with others
Think better of others who use manners

People generally:
Don’t like being yelled at
Don’t like being treated as though they don’t know anything
Don’t like to be gossiped about
Don’t like being ignored
And most of all, people usually don’t respond well to others who demand things rather than ask.

Using manners in all your communications is the very first thing we can all do to improve our ability to gain respect from others. Sharing our experience in a helpful and mentoring way is another step.

Saying “Thank You” and “please” and “excuse me” are things we all learned in kindergarten or early on in life. For some reason these basic skills get lost as we grow up and become members of the workforce. I respond much better to someone who says to me- “Could you please get the door for me” vs. someone who says- after the fact- ‘Why did you slam the door in my face!?” (Usually said behind my back in some gossip session and usually I had no idea the person was right behind me and needed help!) Two good things can happen with this example: The other aide feels good because he/she got a helping hand with the door and I feel good because I was able to help. So simple yet so often not done.

Since many of us have years of valuable experience as CNA’s, we have much to share with the new CNA’s fresh out of class. Many experienced aides think it is not their responsibility to mentor new aides; they feel new aides should know everything they need to know. This might be true as far as basic skills with bed making and vital sign measuring, but NOT with the other subtle skills of getting along in a fast paced environment. Skills with speed and organization need to be talked about. The way in which we choose to teach these skills can really have an impact on our profession.

If experienced aides choose to mentor the new aides with an attitude of negativity and “Just one more thing to do”- we will fail. One has to have a positive attitude and one has to respect the position of the new CNA. Remembering what it was like when we were brand new HELPS.

Respect with leaders is a harder issue. Many nurses think that because they have a degree they automatically deserve respect. This is true only so far as the fact they got their education and degree- everyone should respect others for this. But to respect someone ONLY because of their educational status is not always possible. I firmly believe that respect MUST be earned. Nurses who treat CNA’s with respect, who use manners and who seek input from the CNA’s will manage things far better than those who “demand” respect simply due to their title. I am not advocating disrespect for nurses, but don’t give it automatically. You treat them well- with manners and dignity and hopefully they will respond the same towards you. Also, when respect is handed out without any perimeters staff tend to become like the leader. This can be both negative and positive. A leader who yells and is just miserable tends to have staff with the same attributes working for them.

So, using your manners and being polite DO go along way with respect. Sharing your knowledge and skills in a positive way also help move our profession in a good path. Not handing over respect just because someone demands it makes you a better person because you have standards for respect. What about respecting the residents?

Residents should always have our respect-unlike nurses and others- simply because they have lived long lives and because they are the paying customers within the LTC setting. They are our bosses. Without them we would not be getting a paycheck.
Residents of the Greatest Generation often fought in the world wars and lived through the Great Depression. Respect for this is expected and we should all give it! And we should be grateful. Members of this generation gave much in order that we can be as we are- they sacrificed and suffered for freedom and for American way of life. Never underestimate their sense of duty to their country.

Again, as with peers and leaders, using our manners and being sincere with our efforts will go a long way towards having good relationships with residents. This generation really expects manners and they tend to have different ideas about work ethics and how to raise children. Politics and religion are often taboo subjects with the elderly. Using correct names and titles are expected and show respect. Nicknames, although cute and becoming, should always be “Ok” with the resident and they must respond well to them.

CNA’s need to respect the values of the older generations. Currently, for example, the US is involved with military operations in Iraq. Many of the current generation (younger) feel no need to get involved with this war and are very much against it. Members of the older generation, if they know about the war, probably feel quite differently about it. They most likely feel it is the duty of every American to join the military services and serve the country. These current events can lead to hard feelings between generations. No matter how strongly one opposes war or sees a need for it, always respect how the Greatest Generation feels. Remember, they have sacrificed much more than we have.

Question Of the Week: They Won't Let Us Call Out

Question:
At my facility we're not allowed to call out! Lately there's been a lot of call outs and even more aides quitting. So we work short all the time. A couple aides have hurt their backs too cause we're short all the time. Anyway I got the "bug" last week and had a fever, vomiting, and diarrhea. I felt horrible. I couldn't eat anything; I couldn't keep anything down. I called work to let them know I would be out for my shift and they put me through to the DON. who told me to come in for work, to report to her prior to clocking in so she could assess whether I was too sick to work. If I didn't follow this directive, I would be terminated. SO I went to work and the DON took my temp (101.2)- she gave me Tylenol and a couple spoonfuls of Pepto Bismol; she told me report for duty. If I didn't feel any better in an hour to come back and see her.

Is this legal???

Answer:
Your email tells me your employer is having a hard time with staffing. It appears that the place is going through a downward spiral of problems and management is part of that. When an aide shows up for work, sick with fever and infection, she exposes not only the residents, but her co workers as well.

It's very likely more than a few will catch the illness. So, it spreads like a fire. As each aide comes down with the bug and misses work, management feels it has to do something to curb what it perceives to be an abuse of attendance policy. Management should be prepared for a staffing crunch knowing a virus is going around. But, this facility's management is punishing the very people who are out in the battlefields where the germs are located. It's old fashioned and autocratic.

Instead of being proactive, the DON is being REACTIVE and in a very negative manner. Her actions are telling her staff that she doesn't trust their judgment on their own bodies health. She is also telling them she has no respect for them. A warm body on the schedule is all that matters, even if that body's temp is 101.

The Legality of this:
If this is a policy, it must be written as such.

I called a lawyer friend and relayed this scenario and she gave me the following advice: Is the DON a doctor or a Nurse Practitioner?? If not, she is straying from her nurse practice laws. Nurses cannot diagnose illnesses, diseases, disorders and the like. Perhaps she is sending staff to a doctor who is legally licensed to perform a medical assessment. She would be smart to do this. She should NEVER give staff ANY medications without a doctors' order. She is putting her license on the line by doing so. She knows this. And is counting that you don't know this.

Legally this practice is not advised for management. They are risking a discrimination lawsuit if this "policy" doesn't cover ALL employees of this facility- so, when the dietary aide or the cook or the maintenance man calls out, the DON/Management must apply this same requirement towards them. They too must come in, be assessed, and determined if they're "healthy" enough to work or not. And this would mean doing so 24 hours a day, 7 days a week. Even on holidays and weekends.

What To Do?
If you find yourself too ill to perform the duties of your job, you can and should call out. However, you should also make every attempt to get better or try to reduce your symptoms so you can work. In other words, do take Tylenol/Advil to get the fever down. Immodium will end just about every episode of diarrhea. After this, if you still feel too sick, call out. Make sure you follow the policy- most facilities require 2 or 4 hours notice.

Have your spouse or a friend make the call for you if you're concerned with being harassed by the DON. Instruct your spouse/friend to take a message but to be firm: You will not be showing up for work. Make sure your reasons are given: Details- fever, vomiting, ect. and the actions you have taken to try to make it better. Then call your doctor and make an appointment. You'll need to be assessed and diagnosed properly; and the MD will need to write you a note excusing you from work. Often, this note will include actual dates you are not recommended to work.

A doctors note will not protect your job.
We need to know this and not rely upon it. The note does give credibility to you though: You're putting the effort into seeing the doctor to find out what is wrong and get better; you're paying money to do in most cases; you want to show your employer you weren't goofing off, ect.

You can still be terminated unless you're a member of a union which has rules on this.

I would not wish to continue employment at a facility where this practice occurs. I would leave on my own free will and seek employment at another place with more enlightened management.

Professional Boundaries

In this article, I want to present a concept that should be well understood by all CNA’s. Here, we’re going to discuss what can happen when we become overly attached to a resident, or their family and the implications this has upon the facility.

One of the better changes for some LTC facilities is consistent staffing. However, this staffing model has created some unintended consequences.

CNA’s develop long term relationships with those we are charged to care for. We grow to love them and will do all the little “extras” for them. Usually this doesn’t present a problem for anyone. But there are times when our relationships become unhealthy- for us, for the resident, for the other residents we’re assigned to; to our peers and to the facility we work for.

Over Attachment
In nursing homes, CNA’s can become too attached to a certain resident, in different ways. The CNA will be very upset if they are not assigned to care for this resident, or, will use their relationship with this resident as an excuse for being exempted from floating to other units. The CNA might spend inordinate amounts of time with this resident, and therefore shortchange the others assigned to him/her. The aide will always cater to this residents’ every whim before all others. This resident will have more needs than all others as well- and these “needs” will increase as times moves along.

Sometimes, the resident develops a fondness for an aide that isn’t healthy. The resident becomes dependent upon the aide’s presence to be happy. He or she refuses to allow other aides to work with him/her. Residents have “bad” days when their favorite aide isn’t at work. I have seen residents who believe they are “in love” with their favorite aides, especially those with mild dementia. I’ve also seen aides who care for patients in short term rehab centers develop “crushes” on these patients. The age difference between patient and aide isn’t that far apart.

Other assigned residents are neglected. Often. Or, the needs of these residents are tended to by the CNA’s peers. This creates a problem for everyone. Resentment sets in and working relationships suffer.

Being Objective
A huge problem with this arrangement, as it’s often called, is when the aide loses his or her ability to be objective. This is a serious concern. We must be able to truthfully report the conditions of our residents. This includes, but isn’t limited to, the residents progress or decline in all areas: Ability to speak, bath, dress, feed self, walk- are all very important. The CNA who is too close to certain residents isn’t able to accurately describe the resident’s true abilities.

This effects the resident directly: A resident who cannot really dress herself can be assessed as being able to do so. This might end up in a care plan…and other aides who work with this poor resident will get frustrated at THEIR ability to motivate this resident. Families are told their loved one can still dress herself when in fact she cannot, and hasn’t been able to perform this task for awhile.

We have professional boundaries
CNA’s are considered to be the professionals in the care giver-patient relationship. A CNA is expected to maintain a therapeutic relationship and not anything else. We have the upper hand because of our knowledge and skills. We are responsible for the care we deliver. Within the ethical discussions on this subject, the care giver always has power over the patient. Many times these relationships are for the benefit of the care giver and not the patient.

When the care becomes intertwined with personal friendships and over-advocacy, it’s not healthy. What is OVER ADVOCACY? It’s when we demand residents be given care, therapies and attention they don’t truly need. This is often where over attachment to a resident’s family starts. This is another whole problem- and the legal implications are high.

Ask yourself these questions. And be honest. If you can answer more than two of these with a YES, then YOU are crossing the professional boundaries. And setting yourself up for a lot of trouble.

* Have you ever spent off-duty time with a patient/family?

* Do you keep secrets with patients/family?

* Do you become defensive when someone questions your interaction with a patient/family?

* Have you ever given gifts to or received them from a patient/family?

* Have you felt possessive of a patient/family, thinking that only you could provide the care the patient needs?

* Have you ever flirted with a patient?

* Have you chosen sides with a patient against his or her family and other staff?

If you find that you’re overly attached, how to manage that? It’s not easy. The first step is recognizing you have a problem. Then, its a matter of distancing yourself from the resident. For some aides this is best done gradually. For others, a total cut off is appropriate. Many times, when the bosses see these problems, they’ll assign the aide to another unit altogether, effectively ending the relationship. I don’t think this is a good way to do this.

A CNA can ask for a change with their assignment. Being open and honest about this will almost always result in getting the changes you seek. Part of being PROFESSIONAL means keeping staffing issues to yourself. The urge to tell the resident, or the family, a change has taken place might be very high. Its best to leave these discussions with the nurse. And, after the resident and/or their family is informed, THEY will prod the CNA for information. Again, professional boundaries must take precedent over individual staff needs.

A note about being attached to resident families.
It’s not as common as resident-CNA friendships. But its much more dangerous. And, many times these relationships are initiated by the CNA.

Often times:
A family will block out all others in the facility and depend upon the aide for all communication. The aide will be put into situations they are not trained and educated to handle. Every word the aide speaks will be heard and recalled. If the aide doesn’t have the right information, or misspeaks, a lot of trouble can arise, legally.

The aide will become a spy, for the family. CNA’s are privy to some information that is private and confidential. The levels of care for other residents is an example. When we have over bearing families seeking information from aides who are all to willing to share, it creates huge management problems. It sets the stage for a turbulent relationship between the FACILITY and the family.
Some aides like to think families have some super power over a facility. This is simply not true. Government regulation and oversight have “power”; as do legal standards.

Other aides will use the family in an effort to be assigned to the resident they want. From my experience, these residents are almost always the ones who are considered “easy to do”– and the aide is simply seeking a guarantee of being assigned to this resident. There has been some evidence of aides seeking permanent assignment to certain residents in hopes of getting some monetary award. These situations are always unethical. The aides involved in this should be terminated from employment and barred from working as aides ever again. They are opportunists.

No matter whether a CNA is overly attached to a resident or their family, it’s not usually healthy. Most times the only way to stop the problems associated with these relationships is to separate the aide and resident. Perhaps, consistent staffing would better serve all if the assignments changed every so often. A couple times a year and all aides would be required to change no matter what family requests are. We all want what is best for the residents. Sometimes though, in order to insure this is happening equally across the board, we have to make adjustments and changes.

Two Week Notices: Why It's Important

Over at the Network 54 CNA Forum a CNA brought forth an issue that must be addressed. This is about giving proper notice when an employee decides to quit their job.

NO MATTER what, a CNA must give a two week notice in order to be considered for re-hire status. Also, it’s the right thing to do. Think about it. If an aide is scheduled to work many shifts but suddenly quits, it leaves ALL those shifts open and often unfilled. Who suffers? The residents, patients, clients fist and foremost. Then the aides left behind to do the extra work. Management has to fill the position and do all the human resource things associated with this: Background checks, abuse registry check, hiring, orientation, mentor-ship if there is any, and on the job training.

In any line of work, it is considered absolutely vital to give at least two weeks notice of intention to leave a position. If one holds a college degree, usually this is a four week or one month notice.

In the Network 54 thread, the aide uses the excuse she was sick and couldn’t manage to work- which is a reasonable issue but would have been better handled a different way. She should have gone to her doctor and got a note excusing her from work for several days. We cannot expect to just ask for time off with no notice and get it. The DON refused to grant the aides request.
The aide quit her job..and then when she felt better she tried to go back to work at the nursing home. She was told she wasn’t eligible for re-hire, because she walked off her job. Her action had a consequence. Further, when she applied for work at other facilities she was not given a good reference- another consequence to her action.

While I sympathize for this aide, I also resent that she felt it was appropriate to simply quit. And leave her co workers the brunt of the work, probably many unfilled shifts of hours open and most importantly, left the residents in jeopardy of poor care. Had she brought in a doctors note we would have seen the same thing, perhaps. But at least we would know she was truly ill (which I don’t doubt) and management would have kept her on staff; she would have returned to work and spared us all the time and effort of training new hires and all that.

Giving proper notice for leaving a job is just the right thing to do. When it isn’t done, there are many who pay the price.

Shift Report: It's Very Important

I have been reading here and there about shift report.

How some nursing homes don’t seem to think the CNA needs to hear report. I think this is not only wrong, it’s bad business and a law suit waiting to happen.

CNA’s are the hands on care giver.

They are the eyes, ears, noses and hands of the health care team charged with providing care to residents. When a resident’s condition changes, does it not make sense that the first, and more often than not ONLY people who will have any direct contact with the resident KNOWS of the change?

Nursing home management, that decides CNA’s don’t need to get shift report are setting the residents AND AIDES up for potential injury, harm and distress. Physical and emotional. Nurses, going down the hall, barking out orders to the aides, AFTER the nurse has heard report is not acceptable. By then we have often done our first set of residents and it’s too late for some orders to be carried out. Or, the resident must be placed back in bed or otherwise inconvenienced. And it wastes time, that which CNA’s don’t have a lot of.

Consider this. A resident fell on evening shift. At the time no known issues resulted from the fall, but the resident needed to be observed and assessed periodically until the doctor could see them the next morning. The doctor tells the evening nurse the resident is not to do any weight bearing activities until he sees the resident. Day shift staff arrive and are given their assignments and are told to go about their job. The aide assigned to the resident who fell has no way to know that a fall occurred… The CNA doesn’t get this info and transfers the resident via a stand pivot. SNAP. A hip is broken.

Consider this. A resident’s urine is noted to be dark and foul smelling. The resident cannot speak for herself but is continent. The day shift aide assists resident to the toilet, where she voids a medium amount of dark smelly urine…the residents usual habits indicate she won’t be voiding again until sometime after lunch. A sample was needed from the morning void but that info was never passed on to the aide in time. Now the resident must endure many more hours of discomfort and pain from the UTI she has, all because of a lack of communication.

A resident was up most the night. For whatever reasons, he could not get to sleep. He is known to have behaviors, and a trigger to this is being tired…the aides don’t get report. They find him in a deep sleep and think, “Oh well, he has to get up to eat!” and wake him up…and the aide gets punched in the face. A nice black eye and broken nose are the result. And time spent at a doctors office, ex rays, pain and suffering…all on worker comp billing. Because it was never passed on in report to allow the resident to sleep this morning.

Shift report is vital to CNA’s.

We NEED the information…even when it is repetitive and mundane, it is important. CNA’s must have this information BEFORE they asked to provide care. The little details are often so helpful to us. When we know Mr. Jones hasn’t slept all night, we will allow him to sleep in, to be the last resident we get out of bed. When we know Mrs. Smith might have a UTI, we will collect a sample – many times without being asked. When we hear that Ms. Brown fall last night, we will ASK if she is able to do any weight bearing.

Report doesn’t have to be this long boring ordeal.

Many facilities only pass on information that is out of the ordinary; the typical, usual and common information doesn’t always need to be shared. Normal vital signs, BMs, percentages of meals consumed and cc amounts of fluid intake are not overly important, especially if this information is logged in a book somewhere. On the other hand, elevated temps and B/P’s DO need to be passed on; a lack of a BM in 5 days NEEDS to be passed on; consumption of NO fluids has to shared.

Part of what every CNA needs is information.
We use our training and experience to make everyone’s jobs a little easier; to make our residents comfortable. We depend upon good communication from previous shifts and nurses to provide care that is safe and appropriate. Nursing home management should always insist CNA’s take part in shift report. It should be a mandatory expectation; and, taking this one step further, if an aide shows up late for work, he or she should NOT be allowed to take an assignment until they hear report.