Couldn't believe he did this...

Nurses General Nursing

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I work as a nurse delegated CNA in a very small adult family home that is state certified and actually takes place in a big house, not a facility. It's actually a pretty neat set up as it truly feels like you're in a comfortable home and not in an institution. That said, because we are super small and independently operated, there are only two CNA's on staff and that's it. No RN's, no doctors, no anything. However, we do not administer anything beyond oral medications and insulin injections. We don't take anyone in need of acute care, so it's not a place designed where nurses must be present at all times anyway.

So, my schedule recently changed since I'm in school and I now work with someone who has a lot of experience in LTC (20+ years) and has been working for this company from its beginnings (which is still fairly new, less than 5 years in operation). He is a nurse delegated CNA like me. I am a new CNA, but personally? I don't like to work with him. He does things "his" way rather than what is normally expected and it drives me nuts as I am the type of person that likes to follow rules and regulations to the letter, especially when it comes to other people's health. He does a lot of little things that bother me, such as having the diabetic patients already eating before he takes a supposed fasting glucose test, is very vague in chart notes (says someone ate and drank "adequately" instead of giving measurements/ratios), things like that.

To make a long story short, he made a major med error by giving a resident someone elses meds. My heart dropped. I understand people make med errors, but that to me is a HUGE error. I always follow the 5 rights because I am paranoid of this exact scenario potentially happening, so I do everything in my power to not let it happen when I am the one administering. But more disturbing than this is that he didn't make a big deal about it at all. In fact, it was as if nothing happened. I said that I was calling the manager to tell them right away of the incident. He says, "Oh, don't worry about calling her. It's not a big deal. I'll just chart about it later. And anyway, it's not like the medications that this person is taking will effect the other person adversely anyway."

I felt my heart pulsating violently in my chest in anger. Does RN, MD, or PhD follow your name in any way, shape, or form? Are you a pharmacist or pharmacy tech? If the answer is no, you don't know JACK about how that medication well effect that resident! This is the kind of error that could potentially kill someone! And to have no sense of urgency is just...I couldn't believe it. Oh, and he didn't even chart it. This whole thing was just so, so wrong. He should have known better. It shouldn't have even been a hesitation. The fact that he didn't even want me to call and to just keep it quiet...OMG. No. I advocate for my patients, thank you very much, and to hell if I was going to just sit back while a resident has someone elses meds pumping through their system with no one speaking up for them!

I only had a few minutes left on my shift when this all went down, and decided that I was going to call the manager immediately after getting off to tell them what happened and I did. They were shocked and appalled and both the manager and the owner drove to the home that night to address him. They called me while I was home, put me on speaker phone so he could hear me, and I explained the entire thing from beginning to end. The owner asked him if my account was accurate, and to my surprise the CNA said yes, everything I said was true and accurate.

I am not sure what disciplinary action happened, but it's going to be extremely awkward when I have to work with him next shift. Ugh.

:/

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First, good for you for reporting it and realizing the potential harm to the patient.

Second, I can't believe CNA's are allowed to monitor glucose parameters and dose/administer insulin, and give meds in the first place. This blows my mind.

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Thank you, I appreciate that.

And yes, CNAs can be certified to be nurse delegated to administer various medications (including narcotics) and also nurse delegated specifically for diabetes in my state (which allows us to take blood sugar levels with a glucometer and to administer insulin injections).

I know that many RNs do not have the best outlook on nurse delegation and I understand those feelings (this example being a primary reason why). However, I don't mean to toot my own horn at all, but I am very good at what I do and I'm extremely aware and careful. I do not take it lightly and I report everything. When I give insulin injections and measure dosages, I know what I'm doing and the nurse who delegated me thoroughly trusts me, which I am very grateful for. I have yet to make a med error.

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What kind of training/education was required for you to be able to do this? I'm glad you stuck to it and turned that guy in. Good for you in doing the right thing.

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What kind of training/education was required for you to be able to do this? I'm glad you stuck to it and turned that guy in. Good for you in doing the right thing.

The state has it set up as an online course. Nurse delegation is 9 hrs and diabetes nurse delegation is separate at 3 hours. You complete modules, watch videos and take a test on it. When you pass you get certificates printed for them. Then, a nurse physically shows you how to do it, then watches you do it three times before you're okay to do it on your own without an RN being present.

I was scared at first about giving insulin, but then when I actually did it I realized how easy it was.

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And we can also be delegated for wound care, mainly just dealing w/ bedsores. We have to be delegated to use appropriate bandages/barrier cream/barrier film/saline to cleanse the affected area, etc.

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So if the nurse delegates it, and you do it, and you mess up (much like your co-worker) the RN has to take full responsibility for your actions or inactions?

I am an LPN and my pharmacology was a 6 WEEK course of study in itself, then onto clinical practice of same. And if you didn't pass the pharmacology exam, you didn't get to move on.

I understand that UAP's in "homes" usually observe the residents taking their own meds, usually from a pre-poured box that an RN pre-pours. When you start administering medications, this is where I am not sure I would take that sort of responsibility.

And as you noted, you also do wound care? That in itself is NOT something I would take responsibility for either. That goes into another territory of why the resident is getting bedsores, assessing the skin, and tracking to be sure it does not get worse, there's mapping and assessing with dressing changes. That is something that RN's and LPN's get specially certified for. And something that most state/federal insurances do not re-imburse for. If you have bed bound residents, then they are not necessarily appropriate for an assisted living situation and would perhaps need an alternate level of care.

Perhaps your co-worker seemed so apathetic about the entire situation because at the end of the day, the onlt thing that can happen to him is that he could lose his job. The RN who has done the delegating can lose her license.

There's been all sorts of news about "assisted living" and residents who are/are not appropriate for same. It doesn't matter how "good" you are or are not, careful or not, unless a resident can take their own meds, take their own FBS and know how to dose their own insulin, and are mobile and not prone to bed sores--I would think long and hard about what you are practicing and if you want to continue to be involved in this. Now that this error has happend, the state will perhaps come and look at the processes in place at the home. I think you may find that you all are practicing well outside your scope.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you, I appreciate that.

And yes, CNAs can be certified to be nurse delegated to administer various medications (including narcotics) and also nurse delegated specifically for diabetes in my state (which allows us to take blood sugar levels with a glucometer and to administer insulin injections).

I know that many RNs do not have the best outlook on nurse delegation and I understand those feelings (this example being a primary reason why). However, I don't mean to toot my own horn at all, but I am very good at what I do and I'm extremely aware and careful. I do not take it lightly and I report everything. When I give insulin injections and measure dosages, I know what I'm doing and the nurse who delegated me thoroughly trusts me, which I am very grateful for. I have yet to make a med error.

While I truly believe thart you are very careful......Your co-worker is the perfect example of why nurses have issues with nurse delegation to non licensed personnel.

Patient Safety.

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Correct. We are essentially working off of her license.

There is no medication we give that is "pre-done" by any RN. The morning, afternoon, evening, and bedtime meds are all separated in their bubble packs. We take them out, crush them, mix in applesauce and administer. For liquids, the only liquids we deal with right now are laxatives and one resident receives liquid potassium. They are measured in mL, mixed in their glass at dinner with juice, Ensure or milk (depending on the resident) and administered. We also administer PRNs and need to use judgement calls. We work with residents with severe dementia and a couple of them in particular are prone to outbursts. I find myself administering PRNs of risperidone, trazodone and a topical cream of Haloperidol. Other PRNs include narcotics for pain such as oxycodone, laxatives for constipation such as senna and MoM, etc.

All of our residents will take their own meds in the event that we spoon feed it to them, but otherwise no, they can't take it on their own. They're too confused. Only one cannot walk on her own and that's because a few years ago she broke her hip and is terrified of standing. She needs to be transferred for everything. She is the one who gets the bedsores. We do move her around a lot, transfer her to new places in the house frequently, use pillows to releive pressure, but sometimes they do come back. I am not delegated for wound care and am not in a hurry to speak up to be delegated for it either. The one who receieves insulin can never do her insulin on her own. She is the most far gone from dementia out of all of them. I would never want an insulin pen in her hand...I shudder at the thought (she is also the most violent, so I certainly don't want her in control of a small needle!)!

What ****** me off is that I feel like I am being used from my company. I've only been working here for three months and I have all these certificates, and I was started at $10.00. $10 flippin' dollars. It's so much work, so much for two people to keep track of at once, and is a 40 minute commute. They can never afford to have an RN present. They can't even afford to give us any benefits at all. We work holidays, like Thanksgiving and Christmas, and are not paid a cent more for being there those days. Oh, and forget health care benefits, even when you're full time. I'm so uncomfortable being there and the feeling grows each day I work there.

I do feel at times that we are working outside of our scope, but in our state it has become the norm for CNA's to be delegated. It is now part of CNA training. However, I still think our home asks way too much of us for far too little. Not only that, but insulin and FBS is one thing...I would agree that wound care is an entirely different animal that I don't feel comfortable getting involved it. I don't feel comfortable making assessments and such on it, which is what we do. A nurse will be called to come out to look it over and suggest what we do from that point, but beyond that we are the ones in control, not the nurses. And based on my coworkers, that's scary.

I was angry yesterday when a coworker from a previous shift forgot to administer a medication as it was still sitting in its bubble pack slot. I call the manager to inform her. Manager questions the coworker. The coworker says it was rejected from the resident. Ummm...it's still in the bubble pack, meaning it wasn't crushed, meaning it wasn't offered in the first place. Idiot. Way to try a pathetic attempt to cover your tracks for forgetting. These mistakes happen way too often and I want out. I hate that I even have to put in a two weeks notice and endure another second of the mayhem. I especially dread my next shift where I face that guy. Idk how he will treat me, whether he will be professional or not. And I also dread this shift because the workload is not evenly distributed. He does the cooking, cleaning, laundry. I do the transferring, toileting, the changing of clothes, etc. By the time my shift is over I feel dead. I get that he has a bad back, but it's not fair to put all that work on me!

Tomorrow I am giving Fred Meyer my resume and cover letter in person. Yes, a grocery store. Why? Because I want to milk a "simpler" job for all it's worth while I'm still in school (I worked in a grocery store for two years while being in high school and I enjoyed it a lot). And I only make $10.50 now (minimum wage here is over $9), so...yeah. A job in a grocery store that is flexible with my nursing school schedule, pays slightly less but is super close to where I live and requires much less responsibility? Yes please!

I have never heard of a CNA in my area making what I make, and they don't even have the certs that I do. And I've already looked into CNA positions that aren't only LTC (working with the elderly is not my calling, I have discovered) and they weren't biting. Tried hospitals and said I was a nursing student in the hopes that that would persuade them and still no bites. I just don't have enough experience like they would like, and I'm only a first quarter nursing student. But it's fine, I would be happy with Fred Meyer right now. :)

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" ... and one resident receives liquid potassium."

"...We also administer PRNs and need to use judgement calls. We work with residents with severe dementia and a couple of them in particular are prone to outbursts. I find myself administering PRNs of risperidone, trazodone and a topical cream of Haloperidol. Other PRNs include narcotics for pain such as oxycodone, laxatives for constipation such as senna and MoM, etc"

Run away from this house of horrors as fast as you can! Your practicing well outside of your scope of practice. You sound very careful with the way you work but it's only a matter of time before something bad happens here. A few hours of online training is not enough to be providing the kind of care that these patients deserve and require.

Good luck

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" ... and one resident receives liquid potassium."

"...We also administer PRNs and need to use judgement calls. We work with residents with severe dementia and a couple of them in particular are prone to outbursts. I find myself administering PRNs of risperidone, trazodone and a topical cream of Haloperidol. Other PRNs include narcotics for pain such as oxycodone, laxatives for constipation such as senna and MoM, etc"

Run away from this house of horrors as fast as you can! Your practicing well outside of your scope of practice. You sound very careful with the way you work but it's only a matter of time before something bad happens here. A few hours of online training is not enough to be providing the kind of care that these patients deserve and require.

Good luck

Do you want to know what's truly horrific?

We have a resident who has one kidney and cannot eat foods with potassium. However, she receives a laxative that comes from a bottle that looks JUST LIKE the potassium bottle.

One slip of the hand in the wrong glass and she would be dead - or close to it.

Granted, we have it labeled "POTASSIUM!!!" all over it but given the track record of this place and the bright minds I work with...

I hope Fred Meyer hires me... :( I have lots of relevant experence for them, 4 years worth!

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But I would like to say, though I agree that some of these things are a bit out of our scope, they are all legal tasks that we are allowed to be delegated to do. Just wanted to make sure to clarify that in case anyone was thinking we were an "under the table" home or something of that nature. It's all allowed and sanctioned by the state.

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