Ethical advice needed for a new grad...

TheCommuter, BSN, RN · Jul 2, 2013

Nurses who pass medications at SNFs are placed in a really, really rough situation.

Imagine having 30+ residents, all with medications due at 8:00am. The nurse can document that all meds were administered at 8:00am, or she can document that the last 20 residents received their meds between 9:15am and 11:30am.

If she does the latter, serious consequences may arise:

1. She is written up for multiple medication errors for administering at the wrong time.

2. State surveyors might refer her license number to the state BON for med errors.

3. Her employment is terminated for the inability to pass meds on time, even though it is humanly impossible to administer to 30 residents at 8:00am. You need about three hours to safely pass to all those people.

It's a tough call. If you report this nurse, will you report the next nurse who cannot pass meds to 30+ residents at 8:00am? And the next nurse?

There's the textbook world of nursing and a real world of nursing. Don't hate the player. Hate the game. In this case, the game was created in part by nursing home administrators and the corporations who own SNFs because they control the budget (and hence, they control staffing). Pitiful Medicare reimbursement rates are also a part of the problem.

The nurse is doing what she can to survive in a game with too many booby traps and no end in sight.

AnnaleaRN · Jul 2, 2013

I absolutely agree. It is, indeed, impossible to pass the meds in time. I certainly don't hold any ill will towards this "hypothetical" nurse for doing what she feels she must to survive.

Here is the issue that has kept me up tonight. This action of falsifying the time of med administration is not without consequence for the patient. It could be unsafe. Also, I feel like it is a serious violation of a patient's rights.

On the other hand, I don't want to get this person in trouble. As you said, she is just a player in the game.

TheCommuter, BSN, RN · Jul 2, 2013

This action of falsifying the time of med administration is not without consequence for the patient. It could be unsafe. Also, I feel like it is a serious violation of a patient's rights.

Then again, the scandalous SNF nurse/resident ratios that have been created by the powers that be are nothing short of unsafe.

If nursing home administrators and the corporations that own SNFs truly cared about patient safety, the nurse/resident ratio would be a lot lower than it currently is. However, safety takes a backseat to money. In the nursing home industry, profit is the name of the game.

AnnaleaRN · Jul 2, 2013

The all-mighty dollar is clearly king in the field. How does an individual resolve themselves to being a part of something that is so clearly bad for the patient? Is it something like "this is the way it is, but at least my presence may make a difference occasionally?"

I am truly NOT trying to be flip. I'm just not sure how to approach the situation realistically. A job change? A career change?

nurseprnRN, BSN, RN · Jul 2, 2013

If meds are due at 0900, the basic standard is that you have +/- one hour to give them. Therefore, the facility can choose to change the Qam admin times to 0900 from 0800 and start med pass at 0715. I think that this is not "clearly bad for the patient," especially if you are looking at QD or BID meds. I mean, I'm on an antibiotic rx right now and I don't always get to take it spang on Q8hrs, but it's doing its job.

But since this is probably not gonna happen (and depending on when breakfast is, insulins, lab draws, etc.) without some effort, I think your choices should include new job, career change, facilitating culture change, or attitude change.

TheCommuter, BSN, RN · Jul 2, 2013

How does an individual resolve themselves to being a part of something that is so clearly bad for the patient?

Do most patients take their meds at home on time, at the precise time, every time? Nope. Med administration times at nursing homes are arbitrary and arise due to facility policies. Getting routine medications to a long term care resident a little early or a little late is not clearly bad for them.

Nine times out of ten, the physician has not scheduled the resident's morning Lisinopril, Lopressor, Pepcid, Colace and Senna for a specific administration time. He/she simply writes, "Lisinopril 20mg by mouth daily." We only schedule it for an 8:00am administration time because of arbitrary policies, but you can rest assured that when they're at home, the vast majority of patients take their morning meds sometime in the morning, whether it is 6:00am or 10:45am. They simply get the medicine in whenever they can.

I am truly NOT trying to be flip. I'm just not sure how to approach the situation realistically. A job change? A career change?

This happens in different practice settings, including acute care. Try juggling 7 or 8 acutely sick patients on a typical med/surg floor at the hospital. Try getting everyone's meds passed exactly at 9:00am when each patient and family member wants to keep you in the room and monopolize your time.

If someone codes at 8:59am, you can forget about a timely med pass. If a clueless unit manager wants to pull you into a huddle or team meeting when you've got meds to administer, forget about it. If a patient complains of chest pain during morning med pass, you must drop what you're doing and give the other patients' meds later, possibly very late.

I personally think timely medication passes are harder in the acute care hospital setting because the patients are constantly changing from day to day. In nursing homes/SNF, at least you see the same faces daily and can build up to a quick routine.

AnnaleaRN · Jul 2, 2013

Thanks so much for the feedback, everyone. I want to clarify a few things and ask a couple more questions. Please humor me:-)

GrnTea- I am certainly willing to put the effort into making a change for the better of the patient's and the unit staff! I really love my job. I'm also not a quitter:-)

I agree with you that not taking meds exactly on time can be perfectly safe and happens all the time at home. However, the unit I am referring to is relatively acute. We are a "sub-acute" rehab. PICC lines, trachs, etc. We hang IV meds, blood, as well as the patient's regular meds. These folks certainly don't need acute care. However, they are still quite sick.

My biggest concern is the fact that it isn't charted accurately. I may very well be being a silly new grad about this. However, if you can't get it in on-time, and it's not unsafe to do so, why put false information on the medical record?(Again, not being flip. I just want to understand.)

I'm not sure how to change my attitude about the situation. Do you mean to be less rigid about charting administration times?

The Commuter

I have no doubt that timely med administration is difficult in any healthcare setting at least some of the time.

For everyone, I guess the question is:

Do experienced nurses, as a whole, feel comfortable charting late med administrations as on time under circumstances that are not going to cause any immediate harm to the patient?

CaringGerinurse525 · Jul 2, 2013

We do A.M., Midday, P.M. and HS meds at my facility. This came with the "culture change" and trying to make it a more home like environment. If a doctor prescribes me a med and tells me to take it in the morning I would take it anytime before noon. Really it is near impossible to pass meds to 30 residents within the time frame you describe. No harm comes to the patient because they get their morning med at 10am instead of 8am. Especially if it is something such as a vitamin. Now having said that of course you should prioritize who gets their meds when depending on what they receive. Ex: I would give meds to the resident that is to receive BP meds & pain meds before I would give meds to someone who receives daily senna and vitamins. Nursing is all about prioritizing and using nursing judgement.

Please forgive any spelling/grammatical errors as I am posting from my cell phone!

allnurses Guide · Jul 2, 2013

My biggest concern is the fact that it isn't charted accurately. I may very well be being a silly new grad about this. However, if you can't get it in on-time, and it's not unsafe to do so, why put false information on the medical record?(Again, not being flip. I just want to understand.)
I'm not sure how to change my attitude about the situation. Do you mean to be less rigid about charting administration times?
The Commuter
I have no doubt that timely med administration is difficult in any healthcare setting at least some of the time.
For everyone, I guess the question is:
Do experienced nurses, as a whole, feel comfortable charting late med administrations as on time under circumstances that are not going to cause any immediate harm to the patient?

I do not feel comfortable charting anything that is not true. So, no I do not feel comfortable charting late med administrations as on time. And I won't do it.

I work in a rural hospital and when I was first hired the acute nurses had to work in our LTC units at times to help cover for absences.

My philosophy is if my place of business doesn't have enough staff to safely carry out a med pass in a timely fashion, then that is their problem. I would start my med pass and chart exactly the times the meds were given. Kinda surprised my boss - but I told her I would not lie and she needed to fix the problem.

If the system is broken, then we help it stay broken by cutting corners. And no, this isn't safe for the patients. I won't cut corners.

I made that clear with my superiors too. They stopped sending me to LTC. Unfortunately, the same problems continue to happen. If I were you, I might find a different place to work but make sure you explained why you were leaving.

Altra, BSN, RN · Jul 2, 2013

For everyone, I guess the question is:
Do experienced nurses, as a whole, feel comfortable charting late med administrations as on time under circumstances that are not going to cause any immediate harm to the patient?

Can only speak for myself, but my answer to this question is: generally, yes.

To put this into context, consider the logistics of designing systems and processes to provide care to more than one patient in an institutional setting, and remember the "can't see the forest for the trees" analogy. Many maintenance meds are daily. In order to ensure that they are given daily, and at approximately the same time daily in accordance with basic pharmacologic principles, some arbitrary time has to be chosen as when the meds are "due". It can be 8am, 9am, or 3:18pm ... some time has to be chosen.

There also has to be a mechanism to indicate when actual care provided has deviated from the plan of care. If you give a patient his/her regular dose of a long-standing maintenance med on a particular day at 9:12am instead of 8am, have you really deviated from the plan of care? If your answer is yes, because you want to document that deviation -- what was the indication for altering that patient's plan of care? Your charting on each individual patient stands alone on its own merit. Trust me when I say, "I changed my care of Patient A because I was busy with Patient B" will never, ever be acceptable.

As a brand new nurse you are building your knowledge, skill sets and professional judgment daily. Don't sweat the small stuff.

DalekRN · Jul 2, 2013

I worked in ltc and sar for six months. The only thing I ever did on my shifts was the damned med pass. I scrambled to get it done on time and safely. I had a med error and it scared me enough to leave and go to a different safer setting. The fault is the nurse to patient ratios. Absolutely. If I had another nurse splitting my med pass with me I could have spent more time really assessing patients, crushing their meds in exactly the pudding flavor they wanted, staying the required time during a breathing treatment, etc. It almost makes me cry thinking of the special care that those residents deserved that I was unable to give. Shame on the way that long term care is administered. I know so many nurses working it that work so hard for good complete care and they are heroes, but don't you wish you had a lot more time for each resident?