Is this legal??

[nurseruby]

Because there have been so many "holes" (missing initials on MARs), our DON has established a new policy that if a nurse forgets to initial a med or treatment given,

that nurse AND the nurse who worked right after her

would both be written up! The outgoing and oncoming nurses are supposed to stand there together and look through the whole MAR while the outgoing nurse checks for holes, then both nurses have to sign this daily. The main trouble I'm having with it is ----how can I be responsible (& written up) if another nurse won't initial her work ?? This just doesn't seem legal. Are they just trying to scare us and don't actually intend for the oncoming nurse to be written up along with the outgoing nurse? Crazy!!!!

Ruby

[BrandonLPN, LPN]

Although your scenario is a realistic concern for LTC, staffing is a risk/benefit that the DON has to analyze and determine where the greatest benefit is. Should we do away with nursing reports because it takes away "face-time?"

Of course not. But combing the entire MAR just can't happen every shift change. If you see the last nurse left a hole tag it for her as you go. (I will usually put her initials for her if I know she gave it. But I know that's bound to upset some people here, and there's another thread about that anyway)

[BrandonLPN, LPN]

If you know that you miss documentation periodically and that it is prudent to check your documentation then how can it not be feasible to double-check your work? I am under the presumption that you do give a nursing report during shift change and that you count your scheduled medications so why can you not check the MAR? How long does it take to look at the little boxes, two maybe 3 minutes?

I usually do, unless I'm passing meds right up to shift change. That can happen on a busy night. And even if you do look again it's still possible to miss a box. All I'm saying is in LTC a box will get missed. By some nurses more than others. You say you went over the entire MAR during report. Well, I believe you, but I can't imagine doing it where I work. I wonder how many residents you had? Anyways, yes, if I see the nurse prior to me left a blank I address it accordingly. I don't say "who cares" or something. But I don't treat it as some sort of horrible violation to be concerned about. I know she gave ms smith her coreg. She does every day. I have enough things to occupy my mind. Good lord, if I worried about such things I'd be a basket case....

[Asystole RN]

I usually do, unless I'm passing meds right up to shift change. That can happen on a busy night. And even if you do look again it's still possible to miss a box. All I'm saying is in LTC a box will get missed. By some nurses more than others. You say you went over the entire MAR during report. Well, I believe you, but I can't imagine doing it where I work. I wonder how many residents you had? Anyways, yes, if I see the nurse prior to me left a blank I address it accordingly. I don't say "who cares" or something. But I don't treat it as some sort of horrible violation to be concerned about. I know she gave ms smith her coreg. She does every day. I have enough things to occupy my mind. Good lord, if I worried about such things I'd be a basket case....

When I worked the cart in LTC it was usually around 30, when I was an infusion nurse it was 60-80. The policy stated by the OP is not a new nor rare policy either...

Some take patient safety more seriously than others I guess, practice as you wish, as you already do. ::shrug::

[217shana]

The nurse was not fired because of one hole she was terminated because it had been idenitified as a problem and nothing that had been implemented solved the problem and she was one of the frequent offenders. No matter how good you are, you will occassionally miss a hole but I worked at one facility where the nurses had 54 holes and 72 holes. We are taught as nurses, if it was not documented it was not done and so were the lawyers. A prime example is we had a nurse that worked Jan 1st. She was dead Jan 2nd. Anything that she did not document on Jan 1st and was going to document or check on Jan 2nd was null and void. I did not say that I agreed with the punishment but it did make everyone see how important it is to go back and check behind yourself. When I have worked the floor, on my next tour/shift of duty, I always go back and look to see if I documented everything. I keep my notes just for this purpose. Patient care is of great importance but in todays's time so is documentation. It has become one of the main reasons Medicare and other insurance providers agree to pay or refuse to pay.

[BrandonLPN, LPN]

When I worked the cart in LTC it was usually around 30, when I was an infusion nurse it was 60-80. The policy stated by the OP is not a new nor rare policy either...Some take patient safety more seriously than others I guess, practice as you wish, as you already do. ::shrug::

Now now, just because we disagree over this topic doesn't mean I care less about patient safety than you do. I realize my often being the dissenting voice against what I perceive to be over-rigorous rules probably comes of as lax or even sloppy to someone who values being 100% by the book every time. I just don't see things as black and white as I think you do. There's a whole lot of grey, whether we like it or not. I guess I'm just lucky to work with nurses who I trust implicitly. Isn't that a good thing, instead of always assuming the worst? I KNOW my fellow nurses on other shifts give all their meds and are competent. That's why, on the rare occasions I see a hole in the MAR, I'm not worried about it. If the book were riddled with holes or if the cart was full of more pills than it should have, then yes I would have some real pt safety concerns. Making sure that the MAR is TOTALLY hole free before I even start my med pass will never be a priority for me. I KNOW my coworkers. If she had a rough day and didn't medicate everyone by the time I came in, we would be on the floor together finishing things up. Isn't that so much better than an atmosphere of paranoia and mistrust? Where's the camaraderie?

[Asystole RN]

Now now, just because we disagree over this topic doesn't mean I care less about patient safety than you do. I realize my often being the dissenting voice against what I perceive to be over-rigorous rules probably comes of as lax or even sloppy to someone who values being 100% by the book every time. I just don't see things as black and white as I think you do. There's a whole lot of grey, whether we like it or not. I guess I'm just lucky to work with nurses who I trust implicitly. Isn't that a good thing, instead of always assuming the worst? I KNOW my fellow nurses on other shifts give all their meds and are competent. That's why, on the rare occasions I see a hole in the MAR, I'm not worried about it. If the book were riddled with holes or if the cart was full of more pills than it should have, then yes I would have some real pt safety concerns. Making sure that the MAR is TOTALLY hole free before I even start my med pass will never be a priority for me. I KNOW my coworkers. If she had a rough day and didn't medicate everyone by the time I came in, we would be on the floor together finishing things up. Isn't that so much better than an atmosphere of paranoia and mistrust? Where's the camaraderie?

I apologize if you interpreted my statements as pejorative, I can assure you that they were not meant in an irreverent manner.

Documentation and patient safety are correlated concepts and cannot be disassociated. The crux of the issue stems from either a contention over the significance of patient safety in nursing practice or the role of documentation in patient safety, I presume the latter.

No one suggests that any nurse can practice with total precision and absolute perfection, the ideal is to strive for total precision with a goal of perfection. Once one settles on mediocrity as the norm then nursing practice falls below what is reasonable and prudent.

Your statement, seemingly heartfelt, speaks to the troubles of practicing nursing and insinuates that since one cannot achieve perfection then there is no value in striving to better ones practice; which I contend wholeheartedly. You value your comradery and genuinely seem to care a great deal of your nursing team. That is a fine value but as a professional nurse you are not in the business of making friends, you are in the business of caring for patients.

You state that you care about patient safety as much as any other but have so far only stated what you dislike about patient safety issues and have not proposed any other intervention to address poor documentation, besides neglecting and falsifying the patient’s records.

[tokebi]

What I see from my experience and this thread is the great divide between those in management and those on the floor. Those holes in MARs occur mostly because nurses are in a hurry, and instead of looking at why nurses are in a hurry all the time, somebody in the management comes up with the brilliant idea of making two nurses responsible for one nurse's shift! And to boot, two nurses have to waste quite some time together just to plug up the hole, and that's one less minute that could've been spent on pain assessment, a minute to prevent a fall, a minute to make a visiting family happy, a minute that could've abated the anxiety and loneliness of a wondering mind.

Seriously, do everyone here understand the sheer amount of initials we're talking about here? It's not just each medication given, that's too easy. For each psychotropic med, we initial and count the number of behaviors for which the med was ordered, each shift. For Remeron, for example, "for treatment of depression m/b sad face." Sad face. Seriously?! Never mind that it could've been ordered just to help the person to sleep. But since its labeled purpose is to treat depression, we've got to have the documented reason to receive it, and we have to count how many times the resident shows "sad face?" Not only for depression, we're also expected to count and document the number of times residents strike at staff, curse, refuse treatment, etc, for the psychotic pts. Now for BP meds, we document BP and HR before giving those meds... reasonable. But here's the thing: we have to write those frigging numbers for each med! If a resident has three different BP meds, we still have those cursed squares to write in those numbers for every single one! How does that make sense? On top of all these, charge nurses are expected to know the exact % of meals, snacks and protein shakes eaten, three times a day, document and initialed. And now, pain assessment. Oh gosh, it's important, I get that (my residents make sure I get that even without all the redundant paperwork.) I initial for each shift and document the pain rating, on top of more detailed assessment and rating whenever I give pain med. Now, we have a dedicated "pain flowsheet" on top of the regular MAR documentation, which does the exact same thing but requires more of our initials.

Rather than coming up with more and more punitive measures, think about why things happen the way they happen. Put yourselves into the shoes of the floor nurses and come up with the solutions to help us, not to make it more difficult.

[morte, LPN, LVN]

YES, YES, YES!

we all know that the EMAR, and computer charting in general, is made for the end user, not the persons doing the charting....wellll, the paper charting is following suit, pain flow sheet, so the surveyor doesn't have to bother themselves going thru the MAR. behavior sheets so they don't need to read nurses' notes. etc....I was thinking of my shift yesterday. 21 patients, i am sure the MAR averages better than 2 pages ea, I know some are 4, at ~ 14 meds/blocks per page, how long do you think that is going to take? on top of which, I received an admit at 1245P. Oh and did I mention, I was house sup at the same time??? cut back on duc. and the end result will improve. cut back on meds, results will improve.

Get mcd reembursement in line with reality, results will improve.

quote:Rather than coming up with more and more punitive measures, think about why things happen the way they happen. Put yourselves into the shoes of the floor nurses and come up with the solutions to help us, not to make it more difficult(quote)

[NamasteNurse, BSN, RN]

When I worked for the big K, we were supposed to go through the other nurses' MAR before end of shift to make sure all the meds were signed off. It lasted less than 2 weeks. And, to top it off, the DON and ADON would call all the managers to the conference room for "signing parties" where they expected us to sign someone's initials in every blank spot. I was one who wouldn't even sign off an A&D on the treatment sheet if I hadn't personally applied it, so you can imagine how eager I was to falsify medical records to make them look good.

I have never asked any nurse working for me to sign her/his initials to something they haven't done.

NOW THAT's ILLEGAL! Yes in capital letters! Facilities try all kinds of ****, that only lasts a few weeks. Who has time to re-check at the end of a shift? An d baby-sit our fellow nurses. Ha, that's never gonna last, nurses are a tough buncha cookies! :)

[Elladora]

Our MARS are paper. We have two books with 40-45 patients in each book.

Our third shift goes through the MAR and flags missing signatures. We sign them the next day we come in. We also flag missing signatures as we catch them.

As for narcs and prns...we have a narc count sheet separate from the MAR. PRNs are documented on the back of the MAR in addition to the front (with reason, results, time, date, initials).

Sounds to me like the DON is trying to make each person accountable by using a little (lot) of peer pressure. It sounds to me like on of those brilliant (sarcasm) ideas that will last a few days then fall to the wayside.