Nursing Home Staff and Their Roles

What are the types of nursing home staff?

Not all nursing home staff are the same, they have specialized roles when caring for your loved one.  In today’s episode, attorneys Rob Schenk and Schenk Firm discuss the different kinds of staff that work in nursing homes and their roles.

Schenk: Hello out there and welcome to the Nursing Home Abuse Podcast. My name is Rob Schenk.

Smith: And I’m Schenk Firm.

Schenk: And as this podcast goes to air, Will and I will be attending a conference that is hosted by the Consumer Voice, which is a nationwide advocacy group for the residents of skilled nursing facilities across the country.

Smith: In the same way that AARP is the nationwide advocacy group for people of a certain age, people who are 65 years or older of age, Consumer Voice is the advocacy group for all long-term care residents. So regardless of their age, they’re the advocacy group for all of them.

Schenk: So if everything goes according to plan as this goes to air, Will and I will be riding around lovely Alexandria, Virginia, where the conference is being held, and we’ll be going to different workshops. We’ll be going to different presentations, and we are actually presenting.

Smith: On arbitration clauses.

Schenk: Yeah, on arbitration clauses and the admission packets of nursing homes. So we’re excited to not only be presenters, but we’re actually excited to hear and learn about different issues with skilled nursing facilities and the residents of them.

Smith: Yeah, it’s a great time and it’s largely populated by ombudsmen from all over the nation, so it’s interesting to get their perspectives on long-term care facilities across the country.

How can nursing home negligence be prevented? By knowing nursing home staff

Schenk: Yeah. So on today’s episode, we always say to our clients and to people in general that if you want to – there’s no way you’re going to be able to eliminate the risk of negligence or abuse in a nursing home. But one way that you can lessen its likelihood is to get on a first-name basis, or at least understand the roles, titles, positions and individuals that are providing care for your loved one. So that’s why it’s important to not only get on a first-name basis with them but kind of understand what they’re doing. What is their role? When they get up and start their shift, what is their objective? And so the different people working in that nursing home, the different things they’re responsible for doing, in this episode, we’re going to talk about that.

So when you walk into that nursing home, there’s going to be – we’ve talked about this before in episodes but it always bears repeating – I always say let’s start at the bottom of the totem pole, but as Will has painfully pointed out multiple times, in actuality, the bottom of the totem pole is the most important person. So Will, talk about – let’s start at the top of the totem pole.

Smith: And just to clarify what he’s talking about, in actual Native American customs, those who were at the bottom of the totem pole, whether they were gods or individuals, were the most revered.

What do nursing home CNAs do?

So starting with who’s at the bottom of the chain of command in a nursing home, so first and foremost, you have certified nursing aides. They’re called various different names. They could be called patient care techs, aides, CNAs, certified nursing aides, or medical assistants. They are individuals that are assisting the resident in the activities of daily living, the vast majority of them. So they’re the ones who start getting the residents up in the morning, start helping them put their clothes on, changing their diapers, their adult briefs, taking them to the restrooms, brushing their teeth, brushing their hair, putting their makeup on, taking them to the shower. They’re the ones making sure everyone’s getting up and at it. And they’re the ones who are passing out, usually, the food trays. They’re the ones who are feeding the residents.

They are the backbone of the nursing homes. They are the ones who when you’re short-staffed, that’s who you’re talking about is that you’re short on CAN help, because if you don’t have enough CNAs, then you’ve got to think about it – people aren’t getting dressed. They’re not getting out of bed. They’re not being fed. So CNAs are the arms, the legs of the different nursing home residents.

When I became a CNA 18-17 years ago, it was a two-week course, and the main part of the learning for us were clinicals. We would go out on the floor and feed a resident or we would change a resident. It was a lot of on-the-job training. Now, though, it’s much longer than a two-week course and can take as long as six months, which is good because even though there isn’t a lot of medical knowledge required to be a CNA. I think that the length of time that I spent wasn’t long enough to weed out the people who probably didn’t need to be a CNA. And they should go through a background check. You don’t want people with a history of assault or drug problems taking care of residents.

Who passes out medicine at a nursing home?

Now above the CNAs – because CNAs do not pass out medicine. They’re not supposed to. That is supposed to be done by a nurse. And typically in Georgia, and I’m talking about my experience for eight years in Georgia – other states are slightly different – but typically in Georgia, the next person in the chain of commands above the CNA is going to be the floor nurse.

What is a nursing home floor nurse?

Now a floor nurse, more often than not, is what’s called a LPN, and that is a licensed practice nurse. It is a nurse who went to a vocational school and got a certification to be a nurse. So they didn’t go – they’re not an RN, in other words, but they do have a nursing license. They are the ones who are passing the medicine out. So if you can imagine, it’s 6 o’clock in the morning at a nursing home, and you’ve got CNAs going room to room putting Ms. Johnson’s dress on, putting Mr. Johnson’s shoes on, brushing their hair, getting them up, and while all the CNAs are running around doing that, you’ve got a floor nurse who is at her medicine cart reviewing the day’s medicine or speaking with the previous nurse, speaking with the charge nurse about a medicine-related issue.

And a floor nurse spends the vast majority of their time going down that hall and passing out medicines. It takes a while because you’ve got to understand, you’re not just going down the hall and going, “Oh, here’s your medicine. Here’s your medicine.” Anytime that you’re dealing with a nursing home resident, not only do they have the right to understand what’s going on, but they’re typically elder citizens, and so you can’t just rush through something. So the floor nurse is going resident to resident, “Ms. Johnson, here’s your medicine that you have to take in the morning before breakfast. Please go ahead and take it now.” Or they’ll put it in some pudding of some sort or some apple sauce. Sometimes the CNA will help them eat it. But they’re going around doing that.

What is the difference between a CNA and an LPN in a nursing home?

So you’ve got the CNA that has really no medical or technical knowledge, some basic stuff, that now has a certification, and above them, you’ve got the licensed practical nurse, who has an 18-month certification that equals a license. They have a license to be called a nurse, an LPN.

There are other things they do as well. They change bandages, do some wound care, or anything else that an RN can do. And to be honest with you, they do it better because they’re the ones who are actually on the ground. You and I were talking about this the other day and you were asking about the ranks in the military.

Schenk: Oh my goodness.

Smith: Go ahead.

Schenk: Let me explain this so we won’t have to digress too far, but like – regress too far? Anyways, my contention, audience, is that it’s not common knowledge that there are commissioned and non-commissioned officers in the United States military, particularly in the Marine Corps. So it’s possible that somebody that has been in the, we’ll say Marines, for a year or two, is higher ranked than somebody that’s been in for 25 years, only for the fact that one is a commissioned officer, entered as a commissioned officer, and one is a non-commissioned officer. My contention is that that’s not common knowledge.

Smith: Anyways, so in the military, the major difference in the ranks is that you have an enlisted, and the enlisted includes NCOs, which are non-commissioned officers. Ignore the term NCO because it’s way too confusing to civilians. But you have enlisted and you have officers. The major difference between those two as a practical matter is that nowadays, officers have gone to college. Every single officer in the military right now, unless there’s some exception of somebody getting a battlefield commission, which I’m not aware of, every officer has a college degree. Enlisted are not required to have that. So my point is, so in other words, you can just get out of – you can be 22 years of age, you just got out of college and you got your first lieutenant commission, and you outrank a sergeant major who’s been in for 20 years because you’re an officer. That’s why they call you “sir.”

Schenk: I don’t think that’s fair.

What is the training for a nursing home CNA in Georgia?

Smith: Fair or not, that’s it. My point is though in the nursing home, as you go up, people tend to have more and more education. The CNA, like for example, when I was in, I had a two-week course. So it would make sense that I was not going to be doing anything very technical. I wasn’t going to be passing out medicine. I wasn’t going to be diagnosing somebody. The LPN was the next person up and they have a vocational degree. They have a vocational license.

What is a nursing home charge nurse?

The next person above the LPN is a charge nurse. Oftentimes, charge nurses are RNs, and the difference between an RN and an LPN is education. You can get a two-year RN degree, but a lot depends on where you are. RNs, a lot of times, are a bachelor of nursing RN. So you’re an RN – you went to four years of college and you’re now what’s called a registered nurse.

But charge nurses, it depends on where you are. Charge nurses can be LPNs. Charge nurses can be RNs. In my experience, the people who are in the trenches doing the work typically know the most about the resident. So if you have a question about your loved one in a nursing home, ask the CNA. Ask that floor nurse, that LPN. Those are the people that you want to get to know. Those are the people you want to become on a first-name basis with and be friends with, because they know what your mom does on a daily basis, because they’re the ones that are getting her up in the morning. They’re the ones that are feeding her, giving her medicine. This is the staff that are out there that are actually the eyes, the ears, the mouths, the legs, the hands, the feet of the nursing home resident. They doing everything for them.

What is a nursing home LPN?

And the LPN and the CNA all have obligations to chart, so there’s a chart for every single nursing home resident that indicates what their output is, what their input is, what their bowel movements are, how much food they ate, what percentage, what are their activities on a daily basis, when do they get a shower, when were they changed? The CNAs and the LPNs are doing a lot of the hands-on charting for that.

But above that floor nurse – and each floor is going to have one floor nurse, and they’re in charge of going through and making sure that everybody gets their medicine, but above that floor nurse, you’ll have a charge nurse. And charge nurses are senior LPNs or RNs. And they’re not so much tasked with individual patient care or resident care, and understand something – I occasionally call the residents of nursing homes patients. They are residents. You call them residents because that’s where they live. We don’t want to treat it like it’s a hospital and they’re patients.

But they don’t have as much one-on-one interaction with the residents. What their main job is overseeing the CNAs and the floor nurses, and a charge nurse is, depending on the size of the nursing home, a charge nurse is probably overlooking a couple of floors. We would have, the last place that I worked, which had one, two, three – three halls: Blue Hall, Green Hall and Red Hall – we would have one charge nurse for all of those. And her job was to respond to emergencies. Her job was to resolve any conflicts that may arise. For example, a floor nurse may be going through medicine and say, “Hey, Ms. Johnson doesn’t have anymore of this medicine. Why is she out of it?” So she’ll take it to the charge nurse who will deal with it while the floor nurse continues to pass out medicine.

They are on call. They may not typically be there at all times. It depends on the nursing home. You will always have CNAs there, right? CNAs are an absolute must. So at any given time, 24 hours a day, seven days a week, there are CNAs. Twenty-four hours a day, seven days a week, there are floor nurses because you have to keep passing medicine out all the time. It’s not necessarily that case with charge nurses. In my experience, 24 hours, seven days a week, the last place I worked had a charge nurse, and they rotate through who’s going to do that.

What is the role of a registered nurse in a nursing home?

Above the charge nurse, you have the director of nursing, typically an RN, and typically the type of RN that has a college degree. So these are definitely getting into officers now, if this were the military. CNAs are privates and lance corporals. Floor nurses, they’re starting to get into NCOs. They’re corporals. Charge nurses could be sergeants or maybe warrant officers. And the DON, that’s when you’re starting to get into your officers.

Schenk: This would be like me talking about how you have bounty hunters as a whole, but then you have the guilds of bounty hunters, which include Boba Fett, Bossk, Dengar, but then you have the Mandalorians that are – Boba Fett was a Mandalorian, but they’re not bounty hunters. You know what I’m saying? The last 30 seconds of what you’re saying just went over the head of everybody unless they’re in the military.

Smith: What’s so amusing to me is that when you said this is like you talking about bounty hunters is that I thought you knew a lot about bounty hunters. I didn’t know you were talking about Star Wars. Like I was like, “Does he watch the show, ‘Dog, the Bounty Hunter,’ a lot? I didn’t know that. I’ve known you for 10 years and I didn’t bounty hunters were something you were really interested in.”

Schenk: No. But Boba Fett gave that away.

What is the role of a director of nursing?

Smith: So anyways, the director of nursing is somebody that’s there typically during work hours only, and she’s the one that’s coordinating all the care plans, all the nursing staff, all the CNAs, their schedules. She is somebody that you go to when you can’t resolve something further down the line, closer down the line to the CNAs. And you can certainly go to her for anything. You can go to the person above her for anything. But if it’s something like, “Hey, Mom doesn’t like to wear this dress on Sundays,” go to the CNAs. Go to the floor nurse. Let them know. It’s just they’re the ones who have the most immediate access to residents. They’re the ones who can put it in the notes and go, “Hey, Ms. Johnson doesn’t wear the pink dress on Sundays,” and they’re going to make sure that happens for you.

What does the director of nursing in a nursing home do?

The DON, for the most part, they don’t have a lot of resident interaction. I’ve known some DONs that were much more interactive than others, but they’re not, for the most part, they’re not passing out meds and doing treatments. And the reason I say for the most part, like in the military, sometimes you will have some amazing leaders who get their hands dirty with the troops, and my brother, who is an RN, and I were talking about this the other day, and we were talking about leadership qualities that we appreciated in the military – he was in the military as well – and ones that we appreciate in the nursing environment. And I have worked at places where when we were short-staffed, I had DONs going in and helping me change residents, doing certain treatments or passing out meds. It is absolutely amazing to have a DON like that. It’s also a little scary that nursing homes can be so short-staffed that you actually have to have somebody that high on the chain of command go down to what a CNA does and help you change diapers. But it happens.

But a DON is an administrative position, purely administrative. Unless there’s a problem, they’re not getting out there in the trenches. Their job is to make sure that all the paperwork and the charting is correct, to coordinate with Medicare and Medicaid, and to make sure that all the intake information is accurate.

Now typically speaking, above – that’s the end. That’s the end of the chain of command for nursing staff. So that’s the last person there is the director of nursing. That isn’t the last person in the ultimate chain of command though. The next person up is actually going to be the administrator. That’s the – I would call them the company commander, the major or colonel that’s over the entire base. And they’re the ones who are responsible for the day-to-day operations, including budgeting, including cost reports, including hiring and firing.

Why is it important to get know the director of nursing?

And this is a person who you’re going to meet and some of them make themselves more available than others, but this is not the person you need to go to when you have a problem, just because to be honest with you, they may not immediately recognize the name of your resident, and that’s not necessarily bad on them – it depends on how many nursing home residents are there.

So you’ve got to think about it – the CNA, they’re usually assigned to the same floor for a given period of time – they not only know who Ms. Johnson is, they know everything about Ms. Johnson. The floor nurse gives Ms. Johnson her meds all the time, knows everything about her. Charge nurse knows Ms. Johnson because she’s constantly rotating around different floors. The DON knows her as well but may not know all the intricacies about her. The administrator, she’s in her office working on budgetary administrative stuff.

It really depends on the nursing home too, but the main thing that I want to bring up here is that you really need to get to know the floor nurses, the ones that are passing out the medicine, and the CNAs.

Now there are a host of other job billets that branch off from nursing and administration. You have people that work in dietary, people who work in laundry, and people who work in maintenance. You have people who work in the front office, and some of these people in the front office are the ones that do the initial administration intakes. They’re the ones who coordinate hair care, which can be a big deal. If you want to give your mom a perm, these are the people you talk to. You’re going to be introduced to all of these people and they’re going to tell you, “Hey, when you want your mom’s hair done, you go to Martha in the business office.” So there are a bunch of different jobs, support jobs, outside of the main infantry unit of the nursing staff. But when it comes to the day-to-day care, it’s the CNAs. It’s the LPNs.

Schenk: That’s right. It’s the Stormtroopers and the director of nursing would be Grand Moff Tarkin, and the administrator would be the Emperor.

Smith: Now I will say this – it is my understanding, I’ve heard rumors, that the billet, or the certification or license of LPN may be going away. I don’t know. But whatever is going to replace it will end up being somebody who went to an 18-month course rather than four years of college and got a certification. So a DON is usually still going to be somebody who has four years.

Schenk: Thank you, Will. That was very impressive, your knowledge of the chain of command of not only nursing homes but of the United States military and my part on the chain of command of the Galactic Empire. So that’s going to actually conclude this episode of the Nursing Home Abuse Podcast. You can consume each and every episode, which drop on Monday, online on NursingHomeAbusePodcast.com or our YouTube channel, or you can check us out anywhere you get your podcasts – Spotify, Google Play, Stitcher, iTunes, Podcast Puppies. And with that, we will see you next time.

Smith: See you next time.