I was a director of nursing in Long Term Care for many years and I hear your concern. What I found to be true when I spent hours working and observing care and nurse supervision on all three shifts is that there is a definite lag in the supervisory skills of those left in leadership after 5pm.It is not necessarily the number of staff but how they are deployed and held accountable. Seven staff members to 25 patients is a patient to staff ration of 4 to1, not a bad or unsafe ratio nor is a ratio of 6 staff to 50. Delegating responsibility and holding staff accountable is key, even on a high acuity unit such as yours. A quality assignment sheet works miracles and standing up to your slacker subordinates make serious positive changes. I forgot to say the nurse is included in the staff to patient ratio and is expected to answer call lights, and not refer to the NA if it is a task that can be completed timely. nanacarol

i worked noc shift for 5 years in a ltc facility. i was incharge of 56 residents and had 2 cna's each night. on average there were 15+ residents on "charting" for acute illness, 10+ fall risks with bed-alarms, 7 gt feeders, 2 wound-vacs, 1 trach, and 3 on hospice (most if not all with bowel and/or bladder issues).   it is a total myth that residents sleep at night. they dont. and all that was only half the building. there were 13 fewer residents in the back and they were less dependant for care (limited assist or less) with the same staffing, 1 nurse and 2 cna's.  we have all tried to get "the powers that be" to allow more staff on night shift, but they all did it when they worked the floor so they feel its ok to do now. i hate to tell them this but ltc isnt filled with the little granny and papa's with walkers anymore. most of the residents in long term care have multiple medical problems, wounds, treatments, and behaviors. i learned to have the hearing of a hawk, eyes in the back of my head, and rollerskates attached to my feet at all times. with all this ranting you all must think i dont like ltc, but i do, i love it. i just want the staff to do the job correctly. i take care of my residents like i would take care of my parents or grandparents and i expect the same from my support staff. and lord knows it would be easier to do the job the right way if there were enough people.  california is going to be changing the ratios for staff to resident soon (or so i am told). 20 to 1 for lvn/rn and 10 or 12 to 1 for cna's on all shifts. maybe this will change things for the better it cant make it any worse.