Hi All!

I am a newer LPN with approx 14 months of experience in an ALF. In my 14 months at this facility we have lost 3 nurses and have had no DON for 9 months. The facility has approx 60 residents and there is one other FT nurse that I trust. We are having huge problems with our physician orders. A typical example is I recently questioned the random appearance of a coumadin order on a res December MAR. I held the med and contacted the Dr for clarification. While awaiting the Dr's return call, I discovered a PO in the residents chart that had never been finished by the nurses on duty that day. In other words the order was there, no one processed it, entered it in the MAR, contacted pharmacy or anything. Outcome was all of us were giving 2 PRN meds to this resident that had been dc'd over a month ago.

I know this is horrible - -and unfortunately a common occurence. My question is under these circumstances how would you set up a system so that no matter who is on duty this mistake stops? The two nurses on duty that day are leaving the facility which means we will be back to agency nurses for awhile - so no accountability for any of them. But for myself and the other remaining FT nurse how can we be sure we are preventing this? What is a foolproof system?? I would hate to have to go through every paper chart every shift......

Any sage advice will be appreciated!

You need a DON.

You cannot carry the liability of all of this on your shoulders. Look for a new place to work and make it your priority before you get in trouble.

As a DON of an assisted living unit, I have created stickers (address label stickers about 1x2") with the following info on the stickers: ____MAR, ____PO book (physician order book), ___Nurses Note, ____Shift report, ___fax pharmacy etc. Whoever receives a verbal or written order attaches a sticker to the bottom of the order page and must initial the line before each item as the new order is transcribed on to each form. These stickers are easy to create and update with info as needed. Hope this idea will help you as much as it has helped my staff. It has helped me to track which nurse is transcribing orders incorrectly since I can tell by intials which nurse did the transcription. Good luck!

Looks like you should apply for the DON position! You have the best skill needed, caring what happens to the residents.

As a DON of an assisted living unit, I have created stickers (address label stickers about 1x2") with the following info on the stickers: ____MAR, ____PO book (physician order book), ___Nurses Note, ____Shift report, ___fax pharmacy etc. Whoever receives a verbal or written order attaches a sticker to the bottom of the order page and must initial the line before each item as the new order is transcribed on to each form. These stickers are easy to create and update with info as needed. Hope this idea will help you as much as it has helped my staff. It has helped me to track which nurse is transcribing orders incorrectly since I can tell by intials which nurse did the transcription. Good luck!

I write that checklist on the order page right when I print the order out. It helps me remember what I still need to do since my brain is on a cruise somewhere right now lol

Unit report

Nurses note

MAR/TAR

Care plan

Lab book(if necessary)

CNA care plan(if necessary)

Also, are the staff doing end of shift and/or 24 hour chart checks? Each order should be verified by at least two nurses.

Looks like you should apply for the DON position! You have the best skill needed, caring what happens to the residents.

That's what I was thinking too.

I'm currently the DNS (DON) for a 90-unit ALF, and even though I have two fantastic resident-care coordinators, plus a core group of experienced medication aides who do all of the chart-checks and order processing chores, I'm anal-retentive and perform my own audits as well. I have to. I've been that nurse who didn't have a clue that one of my residents had an INR of 8 and no follow-up, and I had to answer a state surveyor's questions as to why I wasn't on top of it. I'm never going to be in that position again if I can help it.

The key to maintaining organization, for me anyway, is sticking to a schedule and strict self-discipline. For example, my priority each morning after going through the incident reports and the alert charting, is to grab all the physician orders out of my box in the med room and physically check them off against a list of steps in the process: Was the order faxed to pharmacy? Transcribed correctly in the MAR/TAR, initialed and dated? What is the stop date? Was the order noted in the resident's chart, and the resident placed on alert charting for new meds or changes in dosage? Any necessary follow-up, such as the due date for the next protime, arranged and written on the calendar and the MAR? Resident and/or family notified?

180-day orders are handled in much the same way: the RCCs go through them first, mail them out to the providers, check them again when they are returned, and then I go over them with a fine-toothed comb before they're filed in the charts.

Of course, we all have days when the most efficient system goes to the dogs because a crisis develops and we have to respond to it immediately: a resident dies unexpectedly, a new admission comes in on a Friday afternoon with incomplete orders, or we have to don scrubs and man a med cart ourselves because half the staff is out sick and we're the only ones who can pass pills. But if daily, weekly, and monthly tasks are organized to start with, we can absorb the unscheduled emergency without falling hopelessly behind. I used to be much less disciplined when I started out in AL years ago, and I paid a heavy price for it in high stress levels; it's never been my way to deliver health services in a slipshod manner, but until I learned how to say "no" to the temptation to put off dealing with the tasks I didn't enjoy, I struggled mightily in the DNS position.

One of the other skills I've picked up on the job was streamlining documentation systems, and I've created entire sets of forms that were adopted by a couple of the companies I worked for some years ago. As a visual and kinetic learner, I've always done better with documentation I've developed myself, and fortunately I'm able to teach others to use it with little difficulty on their part. If you have the time AND your company permits it, you may want to experiment with creating your own systems; doing so can give you a sense of control over your productivity, and in the long run may help you get and stay organized.

Hope this helps you, even a little. Best of luck to you!

No DON for 9 months, can't keep nurses? You can come up with a better system and in doing so enable administration to mismanage even more.