Is It OK for Nurses to Do These Things?

[Plagueis]

I am starting LPN school next week, and as a CNA, I was wondering about some of the things that I have seen nurses do in caring for residents, and curious if they were considered "acceptable." I have also heard some "hearsay" stories from other CNAs and LPNs about some of the things they have witnessed. I just wanted to list 3 of these behaviors, and get feedback about whether these items were common, OK, or justified, since I would like to avoid tasks that would harm people.

1. Dropping meds on the floor, and picking them up and giving them to residents/patients anyway. I know that this should not be acceptable at all, and I would always just get myself another pill if I dropped one. However, when I asked about this, I was told that the nurse would get "in trouble" if they just got another pill, especially a narcotic, because admin would wonder if the nurse kept the dropped pill for herself. This action was also justified because the resident was only prescribed a certain number of pills, and that they could never be wasted, lest it would cost the patient more money for meds to replace dropped pills. Is this practice common?

2. What about nurses who hide meds in food to give to patients, and the patients don't know about it, because the patients would refuse the medicine otherwise? I would think this may not work, one reason being that if the patient doesn't eat all of her food, or doesn't drink the drink with the med in it, she wouldn't get the full dose of the med that she needs. Plus, I thought that people had the right to refuse medicine. Is sneaking medicine in food OK? Also, what if the patient or resident has to be fed his meals, and a family member or CNA feeds the resident with the food with the meds in it? Isn't that considered passing meds by a nonlicensed person?

3. What about borrowing prescription meds in "emergency" situations? I am told that this may happen because of some error on refilling a prescription, and not being able to get the refill in time for the dose, so it's okay to get the pill from another patient who has the same script, since it would hurt a patient more not to get her pill on time, than it would hurt the patient (the one whose pill is getting borrowed) who may not need it right away. (This seems in violation of #1 above, where the nurse claims she would get in trouble if a pill is unaccounted for. )

Thanks in advance. :)

[squeakykitty]

Number 1 and 2 are bad practice. Number 3 is "iffy" as well.

[Katnip, RN]

1. "Getting into trouble" is no excuse. If you waste a pill properly, even a narcotic, then there's no cause for suspicion of diversion. I don't know about the certain number of meds or their cost as I've never worked LTC, but I'm sure there has to be a way to replace dropped meds without having the resident run out.

2. You are correct. What they're doing is unethical. Every person has a right to refuse meds unless they've been ordered by a judge (in psych at least) to take them. And what if another resident manages to get a hold of the food with the med in it?

3. I've heard this is common practice in LTC, and sometimes in hospitals. I know it's wrong, wrong, wrong in hospitals. I imagine it is in LTC. What happens if someone forgets to document the action? In my opinion this is never the right thing to do. If a resident doesn't get their med because of an error, then the process needs to be looked at and extra care taken in transcribing and administering.

[Valerie Salva, BSN, RN]

In the real world-

#1. Is not good at all.

#2. Not ideal, but sometimes there's really no alternative.

#3. Common practice. As long as it is thoroghly documented, there shouldn't be a problem. Nurses are often forced by circumstance to pick between the lesser of two "evils."

Usually when LTC pts don't have meds available for them, it is because of a poorly designed and/or functioning system to deal with meds. LTCs do no have in-house pharmacies.

Yes, the problem should be addressed. In the meantime, the pt needs a med now.

Unfortunately, many of the structures and systems that are in place to aide in the care of pts actually function to hinder their care, and require nurses to jump through a lot of hoops.

Nurses regularly need to do things that are less than ideal in order to get their pts what they need.

This is the reality of nursing.

[wooh, BSN, RN]

Unfortunately, many of the structures and systems that are in place to aide in the care of pts actually function to hinder their care, and require nurses to jump through a lot of hoops.

Nurses regularly need to do things that are less than ideal in order to get their pts what they need.

This is the reality of nursing.

:up:

It's all about balancing and finding the lesser of the evils to get through the day and get your patients through the day.

[newtress, LPN]

Aside from what you have listed, I am currently an LPN student and have been to several clinical rotation sites and witnessed numerous nurses carrying out procedures non-gloved. Starting IV's and insertion to complete wound care on stage 3 and 4. OMG.

[suzanne4, RN]

Taking a medication from another patient could actually get one in quite a bit of trouble. Borrowing is not legally permitted, does not matter if the facility does that; but I am sure that they would not be there to back you up if any issues became of it.

If the patient's name is not on it, then you are dispensing and that is not under your scope of practice either, so that can get you into trouble with the Board of Pharmacy as well.

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[Thanet]

In the UK things are done very much differently to the USA. But...

1) Is a no-no but it happens.

2) Giving drugs to a patient without their knowledge is tantamount to rape, physical assault, etc. (You can be struck off for doing this)

3) Common over here, as patients given drugs that are the same, are given from a common bottle.( we do not charge for treatment in the same way you do)

[Babs0512]

#1 -- not acceptable. Meds, especially narcotics, can be wasted with another nurse so that no one thinks someone is taking the medications. Picking meds up off the floor is just nasty - infection control would have a field day.

#2-- in an ideal world, this would never happen, but I have seen dementia patients who refuse "all medications" you try to give them. It's hard to argue, ethically, that a patient who has no short term memory or little touch with reality can make an intelligent and informed decision on refusing medications. ie: by not sneaking their digoxin and lasix, they could go into CHF - so I could see some instances where this would be the lesser of two evils, the other evil, not treating a person who is incapable of making that decision.

#3-- again, should't be done. If pharmacy is open, someone could go down and get the medication, if your a stand alone facility, and it's an important medication, in the real world - people do borrow. I wouldn't borrow tylenol, or colace, but something like BP med, cardiac med, etc... might not be able to wait until the next day. If I did borrow, I would document it informally, or keep a log so that the meds could be replaced ASAP. Still, all in all, a bad practice to get in to.

[AMarie85]

I'm an RN student and a tech on the med surg unit and I also have been witness to some "bad habits" that nurses get into... (Injections with no gloves, reinserting foleys after they've been in the lady parts, ect.) I don't say anything I just note it so that I won't repeat the mistake.

1. If you get a second nurse to waste the med with you can get a new med.... I surely wouldn't eat off the floor and neither will my patients.

2. Patients have the right to refuse against medical advice... It is based on the priciple of autonomy... They can only refuse after the treatment and the consequences of not recieving treatment have been explained... Medicine can be put in apple sauce or pudding so that it will go down easier or if the patient can't swallow pills... But giving medicine without tell the patient is wrong. It sounds like you work in a nursing home and many of those patients are unable to make their own medical decisions any more and that may be why their meds have to be hidden.

3. I see no problem with this one as long as it's definately the right med.... Although I work in the hospital setting and it may be different in the nursing home... Usually pharmacy has every patients' home meds and any other med they are ordered in the hospital.

[mpccrn, BSN, RN]

now here's the difference between the ideal world of school and the real world. do you realize the turn around time to get new drugs from pharmacy? try 1-2 hours, is it worth the arrythmia? NO. will it do more harm to the patient to wait for a clean pill? that's on a case by case basis.

patients have the right to refuse drugs. i've never "hidden" them in food. if it's important, and the patient is not competent, there is usually an IV version that can be ordered.

i borrow drugs from other patients on a daily basis to get them the meds they require in a timely fashion and replace it when their dose comes up several hours later. at our hospital stat means pharmacy must get the drug up in an hour....asap and now orders are 2 hours. and god forbid a patient is admitted during the night, their orders aren't even picked up till 0700.

when i was in school in the late 70's, we were taught to do procedures WITHOUT gloves, yes, emptying colostomies, giving baths, doing injections, inserting IV's.......you don't want to "embaress" the patient by using gloves.........times, they are a-changin! (and some of it for the better!)

school teaches the ideal, by the book and when i have a day in the ICU that meets those standards, i'll be more than glad to practice those ideals. nursing is a judgement call on a minute to minute basis. learn the ideal and you'll have an informed clue when it is important and where you have some latitude.

[Plagueis]

Thanks to all of you who responded.

Katnip posted something about hiding meds in food that I wondered about too, and that is: what would happen if another resident (B) got hold of the food with resident (A) meds in it, and ate it? I have seen residents taking food and drinks off another's tray where I work, so this could happen. Plus, I would personally feel uncomfortable about the idea of feeding a resident who cannot feed herself food or drinks with meds in it, because the nurse just leaves it in the food, and continues on with her med pass. CNAs aren't supposed to pass meds, but if a CNA feeds a resident food with meds in it, isn't she doing just that?

Giving residents pills that dropped on the floor is so digusting to me, and I have CNAs who worked at other facilities who told me that they saw that all of the time. The reasoning that the nurses used to justify that didn't make sense to me, and I will never do that when I become a nurse. (And I would never do that to myself, either, so why would any nurse do that to a patient or resident?)