What Would You Do? A Nursing Home Reality Check for DONs & Nurse Leaders

The Call That No Family Should Ever Have to Make

Yesterday, I received a disturbing call from a family member who had just placed their loved one in a long-term care facility. Within 24 hours, their worst fears became reality.

His bed was saturated—urine stains dried over, only to be soaked again.
His sheets were soiled with feces.
His fall went unreported—the family was never notified.
His urinal sat on his meal tray, a clear infection control violation.
The staffing sheet was outdated—listing February instead of March.

Imagine This Was Your Loved One. What Would You Do?

Now put yourself in their shoes. Whether you’re a DON, a CNA, a nurse, or a family member, ask yourself:

If you were the DON, would you have caught this?
If you were the administrator, would you have acted?
If this was your loved one, how would you feel?

This is not about blame—it’s about leadership, accountability, and the systems that either protect or fail our residents.

The Bigger Issue: Leadership Accountability

As a mentor to Directors of Nursing (DONs), I always emphasize:

✅ Know what’s happening in your building.

✅ Be present when new admissions arrive.

✅ Ensure proper staffing before accepting new patients.

✅ Train your team to respond swiftly to concerns.

In this case, the staffing sheet was outdated, and the team didn’t even know any information about him.

That’s a systems failure.

If you’re a nurse leader, you have to ask yourself:

Did we start a basic CarePlan to address safety concerns?
Did we identify this resident’s incontinence needs?
Was your staff made aware of the resident?

If the answer is No.

That’s how residents suffer, staff burnout, and facilities face citations.

Regulatory Violations:

When I looked at this from a compliance perspective, I immediately saw at least six violations:

Quality of Care

Free from Accidents & Supervision:

Right to Be Informed:

Infection Prevention & Control:

Sufficient Staffing

Safe, Clean, Comfortable Environment:

Residents Rights

Each of these could result in citations, fines, and reputational damage. But more importantly, they represent a failure to provide the care that residents deserve.

Why This Happens (And How to Prevent It)

I get it. Budgets are tight. Facilities are under pressure to keep "heads in beds." But if you don’t have enough staff to care for residents properly, then you shouldn’t be accepting new admissions.

DONs and Administrators, ask yourself:

✔️ Is my team properly staffed on weekends before accepting admissions?

✔️ Do I have weekend managers actively involved in overseeing new patients?✔️ Am I ensuring that every resident is properly assessed within 24 hours?

If the answer is no, then it’s not just a staffing issue—it’s a leadership issue.

My Challenge to Nurse Leaders & Families

💡 For DONs & Administrators:

Be visible on the floor—especially after new admissions.
Train your team to identify early warning signs of neglect.
Advocate for realistic staffing levels.

💡 For Families:

Do your research before placing a loved one in a facility.
Look at staffing ratios and past state survey reports.
Visit regularly

Final Thought: We Must Do Better

This isn’t just about one facility or one resident. This is about fixing the system so that no resident is left in soiled sheets, no fall goes unreported, and no family is left in the dark.

So, I ask again: What would you do?

Drop a comment below—let’s have this conversation.

💡 Need help leading your facility with excellence? [Join my DON Leadership Program] (www.directorofnursingtraining.com)

📥 Download my DON Planner to stay ahead of compliance (Bilquis Ali RN FACDONA, CDONA (@bilquisbali) | Stan)📧 Need coaching? Contact me for mentorship & consulting (consultant@welcometolong-termcare.com)

DONS: THIS COULD HAPPEN IN YOUR FACILITY