Sucide lies: is it CYA or blaming?

Specialties Emergency

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  1. What do you think?

    • 1
      You were doing too much and made Charge look bad for no reason.
    • 1
      You shouldn't have charted anything at all.
    • 12
      You should have just charted he was within the sight of the nurses station, that's enough.
    • 60
      You are absolutely right if this went to court you'd be screwed.
    • 1
      Who cares? You think too much.

75 members have participated

So I had a pt this evening who was suicidal. Blatantly suicidal. He was found in his home with a gun drinking and saying he wants to end it. So he went to the Psych lock down part of the ED and when they attempted to medically clear him there by doing his labwork, they were all out of wack. His sodium was critical, liver enzymes all sky high, glucose in the 40's.

Needless to say he was promptly sent to the medical side to be treated. We were short techs to sit and watch him for a 1:1 so the nursing supervisior sent a tech to us to sit with him, just in case. Well since he was the only pt I had the charge RN pulled the sitter to work the entire dept because we were short techs. I didn't complain but to cover my butt I charted that he was "within the sight of the nurses station, appears calm and cooperative, contracts of safety, charge RN aware."

Within a few minutes I got a call from my charge RN who had been looking thorough my notes. He says that he didn't like it that I implicated him in my notes. He said that if anything were to happen this note would place the blame on him.:wideyed: *****

I charted that because I'm just a staff RN, I have no say in what staff goes where. However if something were to happen, I wouldn't want someone looking at the chart saying, there is an order for a one to one here, why didn't you follow those orders?

THEN the nurse sitting next to me said I should have NEVER charted that. She said, that's like the first thing you learn in school. Pt's are NEVER on a constant observation. They are only on that if they are actively suicidal. I said, but they found him with a gun saying he wanted to end it. Then she said, but constant obs is like if you're preventing them from killing themselves that moment. At any other time when they are calm it's not a 1:1. You should never say that.

WHAT IS THAT?! I've been at many facilities and they've mostly had 1:1's. Not to mention the order clearly says 1:1 suicide watch. The hospital protocol says that someone must be within arms reach. A different RN stated that 1:1 isn't even legal, it's just something hospitals do to protect themselves. Am I crazy? Did i just make this up? Was my nursing school THAT BAD that I missed that lesson? Was she being rude?

SO now my charge is ****** at me thinking I'm trying to blame him if the person off's themself. What do you guys think? Was i doing too much? Was I right, was this CYA? OR are they right that as long as the pt is in view of the nurses station that is good enough? If this were to go to court would i be justified in saying he could be seen from the nurses station or was it prudent to say I did all that i could as a staff RN to follow doctors orders?

what do you think?!

I chart "notified RN" all the time. Being responsible fo those under you is the definition of being in charge.

Specializes in Med-Surg.

Unless there are different policies between the US and Canada for this too, there absolutely is 1:1 supervision. And you have to chart it. And whoever is providing the coverage has to chart hourly and prn. That person HAS to be there if the service has been ordered. When they take their break, someone from the floor has to cover if staffing cannot provide someone for that hour.

If the doctor ordered 1:1 supervision for SI and you don't do as ordered, you are being neglectful. Would you be in trouble for not administering treatment, or taking q15min vitals if ordered? Same thing here.

And if your charge nurse pulled the tech, then she should absolutely be the one responsible. Otherwise, YOU are the one who will be thrown under the bus if the s*** hits the fan.

Specializes in Trauma/Tele/Surgery/SICU.

I agree that your charting was inappropriate, but not for the reasons your coworkers provided. If a doctor orders 1-1 for suicide precautions then both you and your charge were ignoring that order. It is not within an RN's scope of practice whether charge or not to disregard a doctors order. Charge nurse carries with it no special status in terms of scope of practice. Charge is supposed to serve as a resource to the other nurses on the floor, help handle crisises, make staffing decisions etc. but they still have to practice within an RN's scope.

The note you charted would not protect you if the patient harmed himself. You would find yourself in a court of law trying to explain why you disregarded a doctors order. There is no defense for that at all save for reasons of blatant safety. This was clearly not an order that endangered your patient so to put it bluntly you would be screwed.

I also disagree with the way your charge handled this situation. If the floor was short on techs and you only had one patient why couldn't the tech sit and you help out by performing tech duties to help alleviate the strain on the ED? With pulling that tech the charge effectively made YOU the sitter. This is a huge misuse of resources because if they were suddenly hit with an influx of patient's they would need the RN available to see those patient's. The charge was trying to have the best of both worlds in my opinion, alleviate the shortage of a tech and keep a nurse free incase of an influx of patients. The only problem with that is that you were not technically free due to the 1:1 precautions ordered for YOUR patient.

It sounds like your charge was playing fast and loose with the rules and hoping you would go along with it. Personally, I do not think I would trust this charge RN.

I would also like to add that documenting so and so aware does nothing to relieve you of your duties as an RN. I see people do this all the time and they always say it is to CYA. The problem is that it does not CYA. Please remember the test is what a reasonable and prudent RN would do. You need to be very specific in your charting and state what you did to try to remedy the situation. If you find yourself in a situation where either hospital staffing or doctor response is potentially harmful to your patient you need to show the steps you took, that are within your scope of practice, to remedy that situation not just chart so and so is aware.

What I would have done in this situation is maintain the 1:1 myself. If a new patient presents to the ED and I was needed I would have informed the charge that I was not available due to having to maintain the ordered 1:1 leaving the charge to have to make the staffing decision themselves: either work short a nurse or work short a tech period. You may ruffle feathers and you may even lose your job but you will at least protect your license and therefore your ability to seek employment elsewhere.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
This. I wasn't trying to be passive-aggressive in my post, but I would never let this happen to me in real life. I WOULD have gotten the supervisor involved. And if that still wasn't enough, I would sit in that pt's doorway and not leave unless I had relief.
I didn't mean to imply you were slightly passive aggressive Sapphire....I was directing it towards the OP....."I'm only a staff nurse" and will this cover me. The supervisor should have been called. She specifically pulled someone to be with this patient......the charge nurse promptly removed that tech from their assignment to work the floor. If I was the supervisor.....I would make it clear that I didn't pull that tech to do floor care.....and if you didn't need her I would return them to their proper/original floor.

The OP had one patient. If the tech was needed....why could she not leave the nurses station and sit outside that patients room instead of being passive aggressive and charting.....patient seen from nurses station, contracts for safety, and charge nurse aware.....that should have been followed by....supervisor paged.

I absolutely think staff should document when they hit that brick wall of MD refusal to listen and staff being unsafe etc.....but that still will not absolve you from responsibility. I have had staff tell me they are documenting that I was advised and I encourage them to do so........BUT.......She had one pateint....the OP should have left the nurses station to watch the SI 1:1

If it was your only patient, I don't understand why you didn't sit with him. If at any time you needed to get up and do something, you should've just hit the call light and have any other RN or tech relieve you. The point of 1:1 is there is always one qualified staff member watching the patient. And I understand it is important to CYA but that is not the only thing you should think about, you should also think about your patient and that he needed someone there to stop him from hurting himself.

Your charge was wrong here. And the reason why she got upset is because she had a guilty conscience because she knew pulling the sitter to do tech work was wrong.

Your poll doesn't include "I did chart just the right thing." You did. But I would have gone up the chain of command to the supervisor if you couldn't get the charge to reinstate a sitter/aide for within-arm's-reach 1:1.

Specializes in psych, addictions, hospice, education.

What if he had a razor or knife with him that you didn't see on assessment and he slashed himself with you across the hall from him? You and the charge nurse would both be liable.

Specializes in OB/GYN/Neonatal/Office/Geriatric.

People are wrong to assume "charge nurse aware" covers them. If your charge nurse has left you in a dangerous situation then the right thing to do is go to next in charge. You say he was your only patient? Did this not make it 1:1? I think whatever policy the hospital has is what needs to be followed, or what is standard practice. Sounds like you both need to address this for the future.

You could tell your charge nurse that now that you have a 1:1 patient that without a tech or other person to watch over him, that you will be in the patient's room.

You will also be unable to take any more patients.

If they pull the sitter, then you are the one to be there.

Specializes in Most areas of adult hospital care.

It looks like I am with the majority when I say, you did the right thing in documenting what you did. But, I am not sure that would have been enough to keep you out of trouble in the event that the "unspeakable" happened. I would have first went to the charge nurse to ask for reevaluation of the situation and then taken it up the ladder if needed. Our first obligation as nurses is to our patients. Don't worry next time something like this happens; being a good team player is not in our Code of Ethics. Do what you have to to protect your patients.

This is a great thread. Each company/ hospital will inevitably develop its own culture, and apply standard, industry-wide rules in slightly different ways w/ varying interpretations. My thought in your situation would be ask the charge nurse what the "code" or lingo is, so you won't have a repeat of this situation, for a genuine, full-on 1:1 versus a go-through-the motions, just in it for the formality 1:1. That way, you'll know what is up. I would think there would have to be times when even this co-worker and the charge nurse would classify a situation as a true, genuine 1:1. This was obviously not one of them from their perspective.

Oh, and be totally serious and genuine when you ask... like you really want to know and you really feel bad for rocking the boat, etc. It may and likely will sound ridiculous to do this, but this is actually the point, because it might make them realize how ridiculous they were to jump down your throat about a pt that was clearly, to some degree, suicidal. Just ask for clarification and be nice about it. I'd be interested to see what they say. At the very least, they will probably see things more from your perspective, and realize that you were just following protocal and SOP, and honestly, how can they really fault you for that? Esp. since you don't know all of their unwritten rules that go against official policy and could open up all kinds of liability yet.

Where I work high risk suicide means someone one on one sitting right at the bed, eyes on the patient-- not charting, reading, or distracted. The pt could kill or hurt themselves with a piece of plastic, a tack, a chord in the room... If the tech is pulled, then the person with full attention on the pt has to be you and your charge lost an RN on the floor. Stand up and advocate for your patient! This is meant as a life saving intervention!

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