New NP in LTC

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    I am a new NP and have been working in LTC for a little over 6 months. I am having a very difficult time adjusting to this type of environment. I have worked with LPNs, however, my experience with LTC LPNs has not been positive. Just like in the hospital, we have great nurses and then we have nurse who are not so great. In LTCs I have encountered too many not so great nurses. I worry that although I speak slowly and I think clearly and spell lots of what I am ordering the order is transcribed wrong and sometimes not at all. One great example while on call this weekend, I got a call from a facility telling me about a resident who's BS was over 500 on the 7-3 shift, I got the call at 7pm. The nurse told me the pt did NOT have a hx of diabetes and the patient was given insulin without an order for insulin. I asked why was the BS checked, the nurse could not tell me. So I asked many questions, ordered a work up for diabetes including fluids and to call me back with BS at HS (no call back). I tried to call back and no answer at the facility. Only after I spoke with nurse practitoiner for this facility that I found out that this patient was diabetic and did have orders for management of diabetes....Oh my goodness.

    I am not bashing LPNs, I would just like some suggestions. I have spoken with DONs and I have spoken with administrators to no avail. If anyone has any suggestions I am completely open.
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  3. 9 Comments so far...

  4. 1
    Call situations are dicey at best. On my weekends on call, I take telephone call for 1000+ plus dialysis pts.

    When I get called - I always, always document what info was provided to me, by whom and what my orders were. We have an EMR so it is fairly easy. This also allows the NP/PA who's pt it is, to know what was done.

    To be honest, in your case, I would have sent the pt with NO hx of DM and BS >500 immediately to the ER as my concern would have been DKA. However, I realize in LTC setting your guidelines might be different.

    My end result is that even with the one facility where I have to use pen/paper, I document and then send the record to the office to be scanned into their EMR.

    It has saved me numerous times.
    Altra likes this.
  5. 1
    Wow, wow, wow. Aweful, you have to wonder what else is going on there, huh? Why isn't the DON moving on this/ these matters? I would keep pushing and take it to the administrator or above. This is unsafe. I dunno, I'm an RN and have worked with many LPNs. I think just about everyone of them are awesome (well..there is one that I'm trying to mentor/ teach) but some of the new hired RNs that we have gotten (seasoned nurses too) are down right scarey! I can see the above situations that you described going on.

    Keep pushing with the administration..these are med errors that can cause serious harm!
    LTCangel likes this.
  6. 1
    If this happened at MY facility, I would hope you'd call the weekend supervisor, the oncall nurse, or me, the DNS, at home to let someone know.
    LTCangel likes this.
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    I have been a Nurse for 16 yrs. Almost half of that was as an LPN. I earned my ADN and then my BSN. I worked a number of years in Acute Care and am now in LTC. I find that I have worked with great and not so great Nurses who have been LPNs and RNs. I can say the same for NPs, PAs, and MDs. I really don't think you can lump all LPNs in one type of category fairly. Good Nurses come with all levels of education. I believe a good Nurse possesses good common sense and good nursing judgement, but the latter comes with time and experience. In the LTC setting, brand new Nurses are often in charge of a large number of residents without much back up and I believe are often set up for failure. If you are having this issue again and again, I believe you need to start with the Management of the place and some education or re education needs to initiated. I gained much of the skills and judgement that I now have while I was an LPN, but I also had the common sense to know when to ask questions and glean whatever knowledge I could from those around me who were more experienced. I still do. I never want to think I know everything because I don't. I learn something new every shift I work. I also try to help younger or less experienced Nurses around me. In my facility, we seem to use a lot of Agency Nurses who come into the building basically to fill the spot with a warm body and many times that's all we get from them. Many times, they are brand new Nurses walking into an unfamiliar building and they know nothing about our residents and don't seem to want to learn. They just want to pass pills and leave. I don't know what the situation in your facility is, but you may want to find out. A lack of permanent staff who are committed to the care and well being of the residents can be a recipe for disaster. I always hate the RNs are better than LPNs debate because I have worked on both sides and even now I will find LPNs who are surprised to find out that I'm an RN because I actually "work", lol! I'm not sure I answered your question but it sounds as if some education is needed here.
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    LTCAngel, I have been a nurse for over 20 years and I agree with you that lumping LPNs under one umbrella is unfair. As I stated I am NOT bashing LPNs. I have worked with and trained LPNs as a instructor. I have also mentored RN grads.

    Many of the LPNs that I am currently working with are great! However, I have encountered many that have raised my concerns for residents. I have spoken with adminstrators and DONs and many times nothing is done. Some of the LPNs describes these LPNs as a warm body; similar to how some agency nurses where called when I worked the night shift in the ER. I understand I work with a variety of people some excellent, some not so great, some irresponsible, however my concern remains with the residents.

    My intention was not to insult any one or profession but to get suggestions for help.
    Last edit by momnurse6 on Dec 28, '12 : Reason: Incomplete thought
    LTCangel likes this.
  9. 1
    Unfortunately, you can't make people give a crap. And if management allows them to work there and provide that kind of "care," there probably isn't anything you can do about it.
    LTCangel likes this.
  10. 1
    Mom nurse, take heart. If you brought this to the DON's attention, she may well have done something about it. My facility has a progressive discipline policy, and I imagine most do. The other thing is I am obligated to protect my staff's privacy as much as I am the residents. If you brought this to my attention, I would have disciplined the nurse, but I would not be discussing that with anyone but the employee and HR. If you continue to have issues, continue to bring it to the DON's attention. I would rather an NP or MD call me when they are having problems with stuff like this so I can address it than risk the safety of the residents.
    LTCangel likes this.
  11. 0
    We use an SBAR form in my facility in New York to assist the nursing staff in communicating effectively with the medical staff. It took some getting used to for both parties, but it helps with info being documented and communicated appropriately. As for the time of the call and the reason the patient was tested, I would definitely bring that to the DON.
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    Momnurse6,I wasn't trying to say that you were saying any one group of nurses is better than another and I'm sorry if you took it that way. I understand that you probably work with more LPNs. I think it def sounds like a continuity of care issue and I would hope that as others have said that the DON handled the situation but you just weren't privy to it. If these things keep happening, maybe you can ask the DON for a Nurse's Meeting in which you outline what you expect from them when you get calls for orders and the follow up that you require. Education can go a long way in solving many problems. We have a wonderful NP that has been at our facility for about the same amt of time and I would welcome a meeting in which she outlined her expectations and ways that she wanted us to communicate with her. Fortunately, I don't think she's had the same issues you have. I feel having our NP has taken a lot of burden from our doctor and she is available M-F all day to deal with a myriad of issues that in the past we would have had to call the doc and try to explain the problem but he wasn't available in person to actually assess the resident the way our NP is. Sorry for rambling. Sounds like you are doing a great job and you are very contientous and caring.
    Last edit by LTCangel on Jan 12, '13 : Reason: Grammar, spelling


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