CMA (covering my ***): What to do if clinic nurse refuses to see a patient?

[Murse901, MSN, RN]

At my facility (and at most facilities, probably), we have nurses assigned to pill call and a smaller number of nurses assigned to clinic. We do not do sick call/clinic during pill call. If a patient has a routine medical complaint, we tell them to fill out a medical request. If we're not able to determine the severity of the complaint (unable to get a BP, O2 sat, etc on pill call, just going by visual assessment and subjective info), we will call main medical to see if they will see the patient.

Usually, they will see them. The nurses in the clinic know that if a nurse is calling requesting someone see a patient, then the patient must have something going on that's causing a lesser or greater degree of pucker factor for the referring nurse.

Unfortunately, there is one nurse in particular at my site who basically doesn't want her knitting or internet playtime interrupted unless someone is bleeding out from a severe head wound. Anything less than that is rejected (no documentation, no pass along in report, no nothing).

What can I do to cover my *** without implicating the lazy nurse? I'm not interested in stirring up a hornet's nest -- I've complained and complained about this problem before, but until someone dies, administration will do nothing. All I want to do is ensure that I don't end up losing my license and working at Burger King to pay off the settlement to the patient's family if I refer a patient to the clinic, the clinic nurse refuses, and something horrible happens to the patient later.

Do I just write an entry in the chart that patient presented with such and such symptoms, main medical was notified, and leave it at that?

[spongebob6286, BSN, RN]

yeah you can write that that you referred the IM to the clinic nurse. how about the charge nurse? i assume they are 2 different people right? in our facility, if the pill call RN can address the problem then they do it themselves, if otherwise, they call the charge nurse. and if its not emergent but still needs referral then they will put him on sick call.

[Guest371144]

The Sick Call Nurse is refusing to perform her duties according to the job description and post duties. Besides documenting in the medical record your assessment findings and referral to clinic, you need to address this with your supervisor (and hers, if they are different). Determine what the chain of command is in your unit and follow it. Document everything - in other words, provide your concerns in writing to your supervisor and keep a copy. Should there be any poor patient outcomes based on the nurse refusing to see the IM, you have documentation to cover your actions.

Just like with an incident report - do not refer to the poor practice of this nurse in the IMs medical record, but record it objectively in written communication to your operational lead.

Let us know if this helps and/or if the situation changes.

Best Regards,

Lorry

[Murse901, MSN, RN]

Thanks for the replies.

Unfortunately, the problem cannot be addressed by the pill call nurse because there just isn't any time. If assigned to pill call, we spend the first half of the shift pulling meds and the second half distributing meds/documenting MARs either at the window in the pill room or delivering to buildings around the campus (lockdown, psych, other units that can't leave their buildings to come to the main pill call room). This is why we refer to main medical any non-routine medical problem.

There have been times where I have referred a very serious case to the clinic, the nurse refused, and I saw the patient myself in the clinic. However, this ends in me staying past the end of my shift and a slap on the wrist by administration for unapproved overtime.

Also, on evening shift, there is no real charge nurse. There are usually two nurses in the clinic, and one is designated as the clinic "team leader". However, the nurse that is refusing to see patients is the team leader.

As an aside, the evening clinic nurse has no scheduled visits (no sick call, wound care, chronic care, etc). All of the scheduled patient visits are handled by day shift. Evening shift is there to see urgent/emergent walk-ins only, which makes it even more frustrating to have a referral refused.

As I mentioned, this problem has been reported numerous times (by myself and others) to administration, but nothing is being done about it. I just want to cover myself with documentation. I just hope that it's enough to document in the chart that I gave report to the clinic nurse, requested that the patient be seen immediately, and leave it alone.

[deyo321]

I think I would nicely ask her why she didn't think it was neccessary to see the IM. Your assuming she doesn't want her knitting interupted. Perhaps she is aware of the issue from report, or the IM has this malingering behavior or she has planned to meet with them already. Often times CO's will come to me with an IM complaint that I am handling already.

But I think if another nurse was asking me to lay eyes on someone I'd have to have a darn good reason why I wouldn't help out.

If the above was not possible, Lorry gave good advice.

Good luck.

[Kora0880, BSN, RN]

Well if the issue has been adressed many times and nothing has been done, then you have one more resort...report the nurse to the Board, they will do investigation. In the end that is why the nurse is there, to provide care and at least to assess the situation. Legally she cannot refuse to do it. Its against the practice act Im 99% sure.

Good luck and sorry to hear you have to deal with such behaviour. It can be very de-motivating and frustrating!

K

[OldMareLPN]

First it is not truly CMA. You are performing as a advocate for your patient, from me you get respect for that.

You are correct in being aware of limiting your own liability in these situations. If you visually assess a patient, and then send them to medical, you should still complete a SOAP form ... regardless of what you expect the charge nurse will or will not do. You are documenting why and what you saw and why you decided to send the inmate to medical.

If you do not need prior approval to send a IM to medical, just send them with the CO. If they are refused it is on the charge.

If you do not get the needed permission, complete the SOAP and under plan indicate you were refused permission to send the IM to medical and then something like 'Charge nurse consulted and IM instructed to complete Sick Catll 'security to monitor', 'IM given sick call' under P. Remember to 'bite your tongue' and stick to black and white facts.

I hate hearing 'can I show you', 'will you look at', or 'what do you think' while I do my med pass. I say 'NO, don't show me, here is a sick call'. If a inmate wants to go to medical I tell them it is between them and the CO and really try to stay out of it, regardless of the charge telling me to 'assess them'. Sure let me assess you with my tylenol and A&D ointment. Are you breathing. NO? Well go to medical.

Best of luck

[PinkRocksLikeMe]

That is hard, I have been there as well and all I can tell you to do is document! I have finally learned after NO help from our DON that I do have to CMA and also make sure this patient that you KNOW needs to be seen is seen. I started writing....Referred patient to X nurse, at what time and what the complaints where at that time, when I am leaving my shift if the nurse has yet to see this person then I will document again that IM still has X complaints, referred to X nurse at X time... THEN I will get another nurse to look at the patient when they get done with pill call etc...Unless it is urgent, then I will go above the head of the nurse I have problems with. It is a sticky situation and I don't even know if I am doing the right thing, I would be interested in hearing how I could handle better. Good luck to you, I hope you can get a resolution.

EMT Jenn