Potential problem/issue

[Djfrank70]

I am an RN, clinical manager for a home health company. I have to sign off on plans of care done by clinical staff as part of my job. The problem starts here... We have a physical therapist who has been very difficult to deal with in setting vital signs parameters for vital signs that would be reported to physician. She is pissed off that she has to get a complete set of vital signs, especially o2 sats. To buck the system, she has written her plans of care with o2 sat parameters as low as 70%!!! After lots of drama and nonsense that no professional adult should cause, she has starting writing as 80 or 85%. I am not very comfortable with setting a resting o2 sat parameter at 80 or 85% on any patient, let alone patients with extensive cardiac history, yet this individual thinks she has a right to set her POC parameters where she wants. My question is, since I have to sign off on her plan of care is where does my liability end? If something were to happen to this patient due to therapist not reporting an o2 sat below 89%, am I looking at potential for being sued and or/actions being taken against my license because I signed off on this plan of care? It is part of my job duty to audit OASIS and sign off... and so far, the company refuses to address this clinician. Please advise.

[macawake, MSN]

We have a physical therapist who has been very difficult to deal with in setting vital signs parameters for vital signs that would be reported to physician. She is pissed off that she has to get a complete set of vital signs, especially o2 sats. To buck the system, she has written her plans of care with o2 sat parameters as low as 70%!!! After lots of drama and nonsense that no professional adult should cause, she has starting writing as 80 or 85%. I am not very comfortable with setting a resting o2 sat parameter at 80 or 85% on any patient, let alone patients with extensive cardiac history, yet this individual thinks she has a right to set her POC parameters where she wants. My question is, since I have to sign off on her plan of care is where does my liability end? If something were to happen to this patient due to therapist not reporting an o2 sat below 89%, am I looking at potential for being sued and or/actions being taken against my license because I signed off on this plan of care? .

(my bold)

I'm not an American nurse and I can't advise you on the potential risk of a law suit. To me however, the primary concern here is patient safety. I don't understand, does your company allow this physical therapist to make up her own parameters? Is there anything from stopping her from deciding that a respiratory rate of 4/min is satisfactory or a blood pressure of 240/115 is just peachy? I guess what I'm asking, is she and why if that's the case, is she allowed to willy-nilly set her own parameters?

A saturation/SpO2 of 70% is what, a PO2 of approximately 40 mmHg? Yay! Hypoxemia... Even a saturation of 85% is barely 60 mmHg. 70% is a real crappy saturation and 80-85% isn't that great). Neither are in my opinion acceptable standard parameters.

and so far, the company refuses to address this clinician.

In my opinion, they really, really need to. (I personally wouldn't sign off on her parameters).

Edited to add: Do you know why this physical therapist is so reluctant to check vital signs? Considering how extremely easy it is to check oxygen saturation (I assume she's not doing an arterial blood gas), I find it strange that she's making a fuss.

[llg, PhD, RN]

I wouldn't sign off on anything I was not willing to defend in court. If it is your job to determine whether the plan of care is clinically appropriate or not, then it is your job to say "No" when the plan is inappropriate. Learn to say "No" and deal with the consequences.

[ponymom]

Take it to the company's legal counsel. Run it past them along with maybe a case scenario or two. See what happens from there.

[Djfrank70]

(my bold)

I'm not an American nurse and I can't advise you on the potential risk of a law suit. To me however, the primary concern here is patient safety. I don't understand, does your company allow this physical therapist to make up her own parameters? Is there anything from stopping her from deciding that a respiratory rate of 4/min is satisfactory or a blood pressure of 240/115 is just peachy? I guess what I'm asking, is she and why if that's the case, is she allowed to willy-nilly set her own parameters?

A saturation/SpO2 of 70% is what, a PO2 of approximately 40 mmHg? Yay! Hypoxemia... Even a saturation of 85% is barely 60 mmHg. 70% is a real crappy saturation and 80-85% isn't that great). Neither are in my opinion acceptable standard parameters.

In my opinion, they really, really need to. (I personally wouldn't sign off on her parameters).

Edited to add: Do you know why this physical therapist is so reluctant to check vital signs? Considering how extremely easy it is to check oxygen saturation (I assume she's not doing an arterial blood gas), I find it strange that she's making a fuss.

Thanks for the reply. The reason why basically is because she doesn't like to be told what to do. We had a case conference to let all clinicians know what the expectations were. (All vitals, including o2 sat via pulse ox every visit) It's a power struggle, because she is a princess, and a physical therapist who seems to resent having to answer to RNs. She doesn't want to be held accountable for actually calling and notifying the physician if o2 sat is below 89%. As for why the company won't do anything... it seems that all who are in charge are nurses, and do not have a strong grasp of where they stand in relation to the therapists as far as dictating standards of care. We have been unable to get any guidance from corporate policy, as the company has been bought out in the last year or two, and so much has changed, etc.

[Djfrank70]

I wouldn't sign off on anything I was not willing to defend in court. If it is your job to determine whether the plan of care is clinically appropriate or not, then it is your job to say "No" when the plan is inappropriate. Learn to say "No" and deal with the consequences.

I have tried the tactful "No" approach... she pitches a fit, and the higher managers are afraid to make waves. I have even tried to play the 'I will let her think it is her idea' approach by spoon feeding her reasons why the pt is high risk, and asking her if she wants to keep the parameter at 85%. All I get is "yes". Just being a jerk for the sake of being one. If it were up to me, I would have fired her weeks ago.

[Been there,done that, ASN, RN]

I have tried the tactful "No" approach... she pitches a fit, and the higher managers are afraid to make waves. I have even tried to play the 'I will let her think it is her idea' approach by spoon feeding her reasons why the pt is high risk, and asking her if she wants to keep the parameter at 85%. All I get is "yes". Just being a jerk for the sake of being one. If it were up to me, I would have fired her weeks ago.

Then have the higher managers sign off on her plan of care. They are afraid to fire her for some reason, make THEM be directly responsible for her.

[Djfrank70]

Then have the higher managers sign off on her plan of care. They are afraid to fire her for some reason, make THEM be directly responsible for her.

That is basically the plan, but she is off on vacation until next week...so it's kind of holding up progress and billing. :-/

[CrunchRN, ADN, RN]

With? Nurses should be the ones setting the threshold.

[Djfrank70]

With? Nurses should be the ones setting the threshold.

Each discipline sets their own in their plan of care.

[Julius Seizure]

Each discipline sets their own in their plan of care.

If that was really all there was to it, then she wouldn't be required to have an RN sign off on it. It is often the case that the RN acts as a gatekeeper, a last line of safety before harm reaches the patient.

[llg, PhD, RN]

That is basically the plan, but she is off on vacation until next week...so it's kind of holding up progress and billing. :-/

Then so be it. That is no reason for you to approve something that is inappropriate. When the billing is delayed ... the management will start taking it seriously. Be professional and firm. Say things like, "I am sorry the billing was late, but as we discussed before, I cannot sign off on plans that are clinically unsafe and inappropriate," and put it in writing for your protection.