I work in a 60-bed unit that usually includes 10 to 12 Medicare patients. Most of the time, I have an LPN to help me. But for two nights last week, I had to care for all 60 patients with no help except for several certified nursing assistants (CNAs). A colleague tells me that legally, at least two RNs must be present in any unit with Medicare patients. Is this true?- F.T., ILL.

Medicare rules don't mandate specific nurse/patient ratios, but they do include expectations for safe staffing levels. I doubt that the staffing patterns you describe would comply with those rules. Medicare has sued some facilities for billing fraud when staffing patterns suggested that patients couldn't have received the level of care Medicare was paying for.

One RN for 60 patients is unsafe in anyone's book. Ask to see your facility's policies and procedures related to staff-to-patient ratios, as well as procedures for protesting an unsafe assignment. For your own legal protection, communicate your concerns to the facility's administration and risk managers according to policy. If no such policy exists, work to create one. Submit an event report every time you're placed in this type of dangerous situation. If you don't and a patient is harmed, administrators could claim that they weren't aware of the problem and that you were negligent in not informing them of it. What's more, because you're supervising LPNs and CNAs, you could be held vicariously liable if a patient is harmed by someone you supervise.

Regardless of whether your patients receive Medicare, you're inviting legal liability when you work under the conditions you've described.