Cover Your Rear

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    I learned today that a fellow nurse had her license revoked after it was discovered that she had been writing orders to cover treatments in a skilled facility. The doctor refused to accept responsibility for these orders, and the Board served her on toast. NO matter how good our intentions are, in trying to provide the best of care for our patients, the moral is: cover your rear, and call that doctor...NO matter how many times we get cussed out..or hung up on.
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    Some questions come to mind. What kind of treatments were they, wound packing with santyl ointment or a normal saline wet to dry? What were the pts. dx? How well did the nurse know the PCP? I guess what I'm wondering is there must be extenuating circumstances or something that warranted such a serious consequence...
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    I also wonder what type of treatments were being done; and had she talked to the MD- was the MD aware of problems; had she documented telephone calls or conversations with the MD? You have left out some crucial details here. If the MD refused to accept responsibility for orders for treatments, but the nurse had spoken to the MD; this should have been documented in the chart. If the MD is the type who gives verbal orders over the phone and then denies he gave them, the RNs should have another nurse listening on an extension and make the MD aware of that fact, and then both nurses should sign the telephone orders. Yes, we do have to cover our rears in this day and age of malpractice law suits. Your state board of nursing had the right to take her license away if it looked like the nurse was writing orders and doing treatments without a doctors' order.
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    Thanks for your responses. I do not know what kind of treatments were ordered, or what the client's diagnoses was. This happened at a facility I do not work at. I do know that the physician was the medical director of the facility, and even though he had signed the treatment orders after the fact, he refused to acknowledge responsibility, and the nurse who had written the orders was fired, and her license revoked. The buck stopped there. Who
    else do you think, if any, should share the responsibility for the fact that the client lost a foot? I did not know this nurse personally, but nurses who do know her state that she was an excellent practictioner, and are very frightened and and angry...angry enough, to want to throw in the towel and surrender their licenses. "It's just not worth it anymore", a nurse told me today. I'm beginning to think that, too.....
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    The first thing you need to do is get a copy of your states' Nurse Practice Act with all of its explanations, etc. and read it. If you have questions about it, call your Board of Nursing and ask for explanations. Then check your own practice: are you following the Nurse Practice Act? It is the letter of the law for you in your state. That patient lost a foot and I'm sure the patient and his family want someone to pay dearly for that. There are MDs out there who will deny orders, or even give orders when they are called at night when they are sleeping that they don't remember the next day. That's why I suggested getting a 2nd nurse to listen in to phone orders. As long as you are following the doctors orders and you have documented this in the chart along with your assessment of the patient, and you are also practicing within your Nurse Practice Act, you have a legal leg to stand on.
    I personally feel that in this society, every nurse should also have your own malpractice insurance. A nurse friend of mine just got ripped up emotionally by the hospitals' attorney in a lawsuit against the hospital- not the nurse (she had done nothing wrong, but was called in to testify by the plaintiff's attorney). If she would have had her own attorney, she could have been prepared for the deposition and trail ahead of time. Because she didn't have her own malpractice insurance, she didn't realize she'd need her own attorney.
    We are dealing with people's lives every day, and everyone expects us to be perfect, including us. The problem is that we are all humans and we all make mistakes; the nurse you wrote about may have done treatments to the patient because she was trying to help the patient get better; but if she wasn't practicing nursing within her legal boundaries, her license was on the line--and she lost it.
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    If at all possible, please refer the nurse described on this post to Nurseprotect-she needs support and to know that there are still nurses willing to protect the rights of our colleagues and ourselves. Revocation of a license seems harsh. If the physician signed the orders and he did not agree with what he signed I think he might be reportable to the Board of Medicine. I would be able to provide more accurate advice with more details.
    I am sure there were other circumstances but I have found that many nurses are treated with hypervigilance and abuse by Boards of Nursing when they are investigated and disciplined-Yes I have to say that I have observed very fair practices from some investigators and boards but the abuse of our colleagues continues.
    Following the nurse practice act is good advice and the law-but I still challenge ANY licensed nurse involved in direct patient care (no I am not talking about the Clinical Nurse Specialist rounding with the team or the rare practitioner with ample time to assess and treat patients) to work a shift without violating the nurse practice act-and the board often holds you "to the letter."
    Unfortunately, covering your rear is not always enough but it is also always a good idea-but as a profession we need to teach our colleagues how to cover their rear AND keep their job/income/livelihood. This is a big issue with many areas for debate. Nurseprotect's concern is ensuring the rights and protection of nurses undergoing board of nursing investigation and/or discipline. Nurseprotect does not exist to assist impaired or dangerous nurses in "getting away with" legitimate and fair allegations.
    Steven S. Lee, RN
    Chief Voluntary Officer,
    Nurseprotect
    "Been reported to the Board of Nursing?"
    Nurseprotect@aol.com
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    Originally posted by Jenny P:

    We are dealing with people's lives every day, and everyone expects us to be perfect, including us. The problem is that we are all humans and we all make mistakes; the nurse you wrote about may have done treatments to the patient because she was trying to help the patient get better; but if she wasn't practicing nursing within her legal boundaries, her license was on the line--and she lost it. [/B]
    I appreciate the genuine intent to be supportive of nurses in this post but the final sentence is not good enough. This is our colleague-now tell me that you have never written an order "knowing" that Dr X would sign it because that is what she always orders and she knows that you are a good nurse. Was is a violation by the letter of the Nurse Practice Act? Yes Does this mean the Nurse Practice Act needs some revision? Probably.
    This nurse lost her license to practice over this. I just have a feeling that she was not treated in a fair and just manner. I really hope to speak with her soon about her experience. The time will come when we must collectively express outrage against these injustices against our colleagues as the Massachusetts Nurses Association has done against their board. There really is 2 sides to an issue-and yes, some nurses need their license revoked or disciplined. Many of you would be in disbelief if you heard some of the stories of nurses undergoing investigation and/or discipline.
    Steven S. Lee, RN
    Chief Voluntary Officer
    Nurseprotect@aol.com
    btw-Nurseprotect is applying for 501(c)3 nonprofit status and does not seek payment for services. We are nurses helping our own in a time of crisis.
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    The thing that bothered me about this particular case is that the patient lost a foot. That is not the same as, say, giving some Maalox to a cartotid endart. patient with heartburn at 3AM. Whatever the treatment was, a patient usually doesn't lose a foot from a 1 time treatment. There are doctors (and others) in this world who don't want to take responsibility for things that go wrong.Most nurses will tell others when they have a doctor like that. When you work with someone like that, you had better cover your rear and all bases and have witnesses, also. By the way, Nurseprotect sounds like an interesting group. Where do we find out more about you?
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    I am new working at a LTC facility. I had an altercation with a MD on the phone because his secretary called a med order in on a patient and I demanded to talk to the MD. Where do these guys get off, do they think I am stupid or something. They would throw me to the wolves so fast if their was a complication from a situation like that that my head would spin. He told me to talk to the DON that she said it was OK. I warned the DON that he was going around telling people she said it was OK to take verbals from secretaries and if that info got to the wrong people she could find herself in trouble. If anyone does not like what I just did tough turkey, I am staying legal.

    [This message has been edited by oramar (edited November 07, 2000).]
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    Oramar the longer you work in LTC you will find more of what you posted about. I worked LTC for the last 5 years of my career and some of the things I witnessed is enough to make your hair stand on end. I enjoyed working with the elderly, but found after enough crap happened that even more than hospitals in nursing homes the bottom line is money, money, money. I lost a job at a facility after I tried to force the administrator to report falisifation of charting by the DON and MDS coordinator, as well as three incidents of abuse. I was told by corporate people I was not to report them as it was the administrators job. I pushed him and pushed him. Kept thinking I could get him to do it, and save my job at the same time. Finally one day I told him if he did not report it I would. Gave him a time line. 3 days later I was suspended pending investigation, for guess what? Patient abuse. I had stepped between two combative patients to keep them from harming one another and out of that I was charged with patient abuse. The nurse who did the investigation on this for the facility was the ADON, she had only a few months prior to this been charged with felonies related to a time she had been a DON in another facility. Those charges were for medicare fraud, falsification of patient records and destruction on patient records. Just a month prior to my suspension, her license had been suspended by the state because of the felony charges. Her license was reinstated after the charges were dropped to a misdemenor because she testified against higher corporate people. Yet in the facility were I worked at knew this and she was allowed to keep her job, and stay in a management position. The paperwork sent to the investigator from the facility was wrong. It had the wrong dates of suspension, the wrong date of termination. Notes added to the patient records. I was actually fired on a Saturday over the phone. When all this happened to me I did not know where to turn. I went to a labor attorney. I went through the entire investigation process and thank God that the investigator was able to tell that everything the facility sent had been "buffed". She was also able to note that late entries had been made into the patient charts, and in her words, had been made to appear that wrongdoing had been committed where none had occured. Nearly a year went by before I was cleared. It was a horrible time in my life. I was afraid, I became extremely depressed, I didn't work for a year and three months. In the meantime trying to get anyone to listen to me about what should have been reported was extremely difficult. I was viewed as a disgruntled ex-employee with an axe to grind. It took much effort on my attorneys part to bring the issue to the forefront. I sued the facility for wrongful termination, and won. Yet after attorney fees I got about 3 months worth of wages and thats it. To me it was like blood money and I didn't even keep it. I used it to buy my sister a car. In the end the facility effectively silenced me and nobody was held accountable for the falisification or the patient abuse. Oh,sure it came out, but nobody was held accountable. The two nurses that falified charts continue to work, the DON is a DON in another facility, which had no citations. I know why too. The MDS coordinator went to another job as well. Nothing happened to the administrator of the facility and as far as I know he continues in his job. I reported everything to 4 different corporate people, they still are in their same jobs. I'm not telling you this to scare you away from nursing homes, just to let you know that these kinds of things happen and to make sure you don't let it happen to you. I wish to God I had just quit there and went to the state. I live in a small rural community and the place I worked at is close to me. There were many residents there that I had known as a child, people who had been friends with my grandparents, I stuck it out because of them. Somehow I thought I would protect them I guess. This is why I became involved with the million nurse march. Nursing homes must be held accountable for what is going on inside them. Staffing is not adequete, mandatory overtime in many is the norm. The lack of appropriate supplies can be a nightmare.
    I feel for the nurse that lost her license. To me the likely scenerio is that the patient needed to have something done, the physician was not seeing it and not doing anything, trying to get a physician in when it is not normal rounds in a nursing home can be like pulling teeth, so the nurse took it upon herself to do something. Yes, it is against the practice act, but where was the physician in all of this? How about the DON? In my experience it has been the norm for a weekly skin report with measurements and treatments being done to go to the DON for followup. I find it hard to believe that no one but the nurse involved knew what was going on. She happens to be the great scapegoat though. I hope she does get ahold of nurseprotect. I hope she chooses to become involved with the million nurse march. Nurses are made the scapegoats in all sorts of circumstances. How do we do something about it? To become active in our own defense thats how. I just posted this same story on nursing spectrum, I have never posted about this before. I was ashamed of what happened. I knew in my heart that I did nothing wrong, I had tried to what was right. But it still made me feel ashamed. Nearly two years later I have finally made peace with it. But what I have decided too, is that I cannot stand idlely by while this type of thing continues. The industry as a whole must be held accountable for what they are doing to nurses and to patients, all in the name of money. A facility will ruin your reputation and livelihood before it ever allows that to happen to them. I did finally get a job at another LTC facility, I wanted to stay working with the elderly, I have a special spot in my heart for them. But then I was forced to chose whether to go to my dying father or to keep my job. I chose my dad. I am now going with agency so I can control my destiny better, and I will continue working with the mnm, as well as continued activism in some form. This should never happen to another nurse.


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