Given another patient's medication to satisfy MAR.What do you do? Orientee

[rn_nxt_dr]

On my 2nd week of orientation, I saw this happen under 3 different nurses.

The patient's medication packet was empty and the trainer pulled the drug from another patient's medication packet to satisfy the MAR; because as we all say, if it's not documented, it was not done.

The 4th incident was a patient's NPH, no NPH bottle, and the 4th nurse said to me, "I know this is wrong but this is how you do it, take this NPH (another patient's NPH) and draw what you need." I refused and asked for the emergency kit, and it was also empty.

What would you do? Where to report other than LTC Ombudsman? This is criminal and they have to be punished.

[elb252]

When I worked LTC, I would order anything with one week left on the card. That gave pharmacy plenty of time to deliver. Some nurses are lax about med refills, sometimes it's the pharmacy not delivering in a timely manner, sometimes the pharmacy would state they never received the fax. It's always a good idea to follow the fax with a phone call to pharmacy.

That's one of the first things I was taught during my orientation into LTC nursing. It has helped me tremendously. It definitely helps to call the pharmacy just in case something with the fax might be broken, or something is up on their end...etc.

Giving a week in advance gives them PLENTY of time to send meds out. And, if it's Friday and I anticipate that a patient's meds will be low on the weekend, I order more meds to be brought in later that day.

[gvernz]

Tell you what, if you report it to the STATE would it do you any good? Try talking to your supervisor por DON. There is a chain of command, let your supervisors fix the problem internally , give them a chance to discover where they went wrong and try to find ways to fix the problem. Maybe the nurses that you worked with were told the same thing during their orientation. Maybe it has been a common practice among nursing staff and the DON was not even aware of it. Maybe there is a purpose why you are there in that facility. Maybe you will raise the bar on the nursing practice among your peers by being a good example; setting the new standard- BEST PRACTICE!. Remember, you are just starting in that facility, it doesn't make a good impression to be the "bad guy". Believe me, in my previous job we had a disgruntled employee who called STATE on the facility just to get back at the management for being fired and I don't know how the bosses discovered but they knew who it was when the surveyor walked in the building. You don't really want to earn the reputation of being a "tattle tale", DONS have their network among themselves and they asks for references on hiring new staff. Be smart, do not be impulsive and try to think things through before doing something drastic. Be cautious.

[gvernz]

Thanks for all your rseponses.

I did raise the issue with the DON---after the third incident, she told me about the E-kit, which was hardly full, even NPH back-up is not available.

I was told that I will be moving to another position (unnamed), my schedule was re-arranged, I was suddenly asked to not show up on a scheduled work bec. of a new schedule and to call the DON and clarify and I never heard back again.

So, this is LTC? When your own supervisor treat you like a piece of ---- and was just brushed off for raising a relevant issue that may affect patients, much less hurt them?

I called the Ombudsman and expressed my concerns, the rep said that it's a common thing in LTC---they got to do what they got to do. So, I just dropped the idea because they too didn't do anything.

So, this is nursing? I hope to get this to the residents' families and get it to the public to give these nursing homes a boot!

It's an outrage that this is happening---simple procedural drug supply can't even be met. I am truly disappointed.

If there's a DON out there reading this....why do you do what you do and how do you address this?

It may sound simple but this is a violation nonetheless. And these nurses training me who have the audacity to say ----"I know this is wrong but this is what you should do"................

I guess you did what you think was right at that moment. I admire your passion and for standing for what is true and what is right. Unfortunately, your decision to stand for your beliefs gave the wrong impression to your superiors and instead of having a positive outcome, it went sour. Go back to that incident and in your mind's eye ask yourself this question? Did the patients benefit from what happened? Our patients always comes first, specially if it is a medication such as insulin and coumadin- they are high risk medications. For example, that specific patient could have had a high blood sugar result and needed the insulin right away, otherwise, the patient would be hyperglycemic and would have reactions if left unmedicated. Waiting for pharmacy to bring the medication would be a long wait and the patients should not have to wait that long. It is the responsibility of medication nurses to call pharmacy and fax them the RX number of the said unavailable medication. The facility must provide inservice /education to the nurses regarding following protocols in medication administration.

[gvernz]

WOW, ok as a DNS, this is the issue. ALL Nurses, on ALL shifts are responsible, period for reordering ALL meds (not just the meds they give on their shift). The same is true of the e-kit, which is counted every 8 hours, so if you see the red tags, know the ekit has been opened, and still see the white sheet there, pull it out, fax it and follow-up with phone call to pharmacy, until you get that replacement ekit. Go to the other floors for ekit if needed, we have 3 ekits, on 3 units, many, many opportunities to find meds. Re: Coumadin: have your DNS/DON tell pharmacy they want all the mg of coumadin, ie 1 mg, 2 etc so can meet most used doses, and make sure as the DNS, it happens (you are required to hold the DNS accountable just like the DNS is to hold you accountable). I love to get written suggestions from staff, I love that they care enough to tell me stuff.

Unit manager should be consulted immediately, and systems re-activated and nurses retrained. There is NO borrowing, not for any reason. ALL pharmacies can satellite all meds, and if not, again, go to DNS who will now hold her pharmacy accountable (I have the pharmacy head on speed dial and email, he responds within one hour if I email him my issue and med usually shows up about an hour after that).

As a nurse, it is OUR job to be a competent nurse, we know what is right and wrong, I have to know to order the missing meds, ekit, and I know to report these nurses to the management team of the facility.. LTC is evolving and I do not tolerate "old" behavior, and why should any of us? Walgreens will send over any med I need, if it is 0200 or a Sunday, I call the on-call pharmacist, wake him/her up until I get my med, period. And I tell the MD when I can't get a med, as well as the family and the resident, and sometimes the med isn't that necessary and the resident can go "without" or "hold until new dose arrives" there are a variety of MD orders you can ask for. MD will often write order for a med in e-kit say out of Morphine 15 mg, need signed Schedule 2 script at pharmacy, it's a Sunday, MD out of town, the MD can give T.O to administer Oxycodone 15 mg po UNTIL MS comes in, MD calls into pharmacy, there's your auth to pull the other narcotic. YEah, its a bit of paperwork, but the pain is addressed, there is no squablling between nurses, and pharmacy is on notice to make sure that Morphine gets sent out, as soon as MD give signed schedule 2 script.

I think it is a real shame that nurses let other nurses sway them away from what we all know is right. Yes, when I was a new nurse, and I orientated, I saw ridiculous things, (i saw plenty of silly things as a C.N.A as well) and as soon as I was on my own, on a med cart, I did it the right way. I personally re-ordered all the meds, way before they are due, and I did this as a Resident Care Manager, once per week, asked the nurse to let me have the cart for 5 minutes, pulled off all stickers with 8 meds or less, faxed to pharmacy, problem solved.As a CNA I watched countless nurses bicker over narcotic count, said one day "Look, you all have been counting for an hour, you can't figure out the liquid, sign it as count incorrect, call the DNS, you go home and you pass your meds, end of story". Both nurses were so shocked a CNA would say that, they actually followed my directions, and of course, the DNS asked to speak to me what I had seen. Did those nurse like me? Absolutely not and absolutely sometimes yes, but my real concern is good resident care, not a popularity contest. If we don't stand up, who will take care of the residents properly? We need leadership in LTC, not followers who fail to function.

Sorry if this sounds preachy, just hits a nerve with me. There is no excuse for bad behavior, doesn't matter how many are misbehaving. Are we receiving a paycheck for being a nurse? then I expect the nurse to act as a nurse, period.

:yeah:

[itthybitthythpider]

To the OP: you kinda got the short end of the stick on this one. I understand why you were so upset, but going in with the attitude of "you are all criminals and need to be punished" may have been the wrong attitude.... Next time, try working on a solution to the underlying problem, which would be not ordering meds on time. It is a huge problem in a lot of buildings, and was a F-tag in one I worked in.

.......Re: Coumadin: have your DNS/DON tell pharmacy they want all the mg of coumadin, ie 1 mg, 2 etc so can meet most used doses, and make sure as the DNS, it happens (you are required to hold the DNS accountable just like the DNS is to hold you accountable).....

I am so going to have to try this idea! I didn't know this was possible, but I'll have to bring it up to our DON to see if we can implement it.

[pixie120]

I once worked in a building that had a "new" pharmacy and we sat down for a meeting and went over the whole E-kit and told the pharmacy what we wanted in it. Every possible dose of Coumadin is one (not really every mg, a stack of ones, 2's and 5's should suffice, and then get permission from your pharmacy to half the 1's and or 2's, for the first new dose). It's allowed if you have a MD order that says break the one in half, e-kit dose x 1, ok per pharmacist. I think anytime you are "dispensing" meds, breaking tabs etc, get the MD to give you an order, explain why (new dose of coumadin, per MD, Pharmacist and famiy, ok to pull dose from e-kit fo 7.5 mg x 1).

Also, the "idea" that we will all go to jail: everything that we do as nurses requires the following (this applies no matter where you are in the US orthe world):

1. MD order (nurse CANNOT touch a patient without an MD order). (Don't get confused here, many facilities have standing protocals that allow "you" to touch a patient, you may not have a written order in that patient chart, but you certainly have an order for everything you are doing to that patient.)(ICU's, ER's, bowel orders, standing PT/INR labs etc)

2. Everything that you DO to a patient, is FOR that patient ie: he/she needs whatever the MD ordered, OR you have to get a different order. ie: out of the correct tube feed, get MD order to hang the whatever until the correct TF comes, out of heparin, get order for Lovenox x1 etc. ALl of the orders must match what you did to the patient or didn't do.

3. EVERY MD ORDER can be changed, as long as it doesn't harm the patient. GOING without meds, harms the patient. Call the MD "Hey doc, I don't have any Bactrim DS in the e-kit but there is a slew of Keflex, it's Sat night and the pharmacy can't deliver a new e-kit or the med for this patient until Monday, can we give Keflex until Bactrim comes in?

or

Pharmacist (Who you have just woken up in the middle of night) I need YOU to call in a Schedule 2 emergency 10 tabs to my pharmacy so I can pull from the e-kit or have the pharmacy satellite med from Walgreens (then write the order however it goes down).

4. DO WHAT A REASONABLE and prudent nurse would do, in every situation. IF you cannot meet the needs of that resident at that time in that facility, send them out to the hospital. If MD refuses, go over MD head and send via 911 (because the MD of record is then the ER MD) and call the family, DNS and tell them why you did that (for thegood of the patient)

Apply reasonable and prudent to "borrowing" meds: not reasonable,not prudent. It doesn't address the issue/problem at hand, and you haven't included the MD in making a decision on HIS/HER patient (remember, you are an agent OF the MD, he/she HAS to know what is going on with his/her patient). It is outside the scope of your practice to make other decisions such as "i will borrow, I will not give,". Borrowing is also considered, by many, to be financial fraud as the patient has paid for his/her meds, you are fraudulantly diverting them to another resident, again without knowledge of the MD.

The e-kits are there for a reason, look inside and find the missing med, or a similiar med and meet the needs of the resident, or get an order to "ok to miss hs nose of SImvastation, until new dose comes in". Clearly, a lot of meds missing one dose won't cause harm.

All of this really relies on critical thinking and if you aren't sure, call for advice. That is what the DON's job is, to guide you to the correct critical thinking pathway.

[limonada]

I don't want to sound dumb, but I'm confused. I understand what everyone is saying here, but I have also seen this happen in my facility. I always order meds in advance but not everyone does. There have been times where I was out of a med so I "borrowed" from someone else who had the exact same med. Our pharmacy makes deliveries at certain times, and if I called to say I was out of something, they would most likely not be able to bring it until several hours later. I have not worked there for very long, but other nurses told me that if you are out of something to just "borrow" from someone else. Even though that is not what you're "supposed to do." But what else can you do? Just not give the med even though another resident has 30 of the very pill that you need for another resident?

[Simba&NalasMom, LPN]

I don't want to sound dumb, but I'm confused. I understand what everyone is saying here, but I have also seen this happen in my facility. I always order meds in advance but not everyone does. There have been times where I was out of a med so I "borrowed" from someone else who had the exact same med. Our pharmacy makes deliveries at certain times, and if I called to say I was out of something, they would most likely not be able to bring it until several hours later. I have not worked there for very long, but other nurses told me that if you are out of something to just "borrow" from someone else. Even though that is not what you're "supposed to do." But what else can you do? Just not give the med even though another resident has 30 of the very pill that you need for another resident?

Although "borrowing" is very common, techinically it should never be done because it's seen as stealing. In my experience, if the med is not available, you are expected to get it from the e-kit; if that is not an option, you do not give it, circle it in the MAR, and write the explanation on the back.

In reality, I have never worked at a facility where borrowing does not occur. Doesn't make it right, but that's the real world. One thing I want to add: you should never borrow; we've established that. But ESPECIALLY never, ever, EVER borrow narcs b/c on top of the stealing thing, it also looks like you are diverting.

[limonada]

We don't have an e-kit. And I have seen people "borrow" narcs too. I think my original thought when I first came across this situation was to circle it on the MAR, but I have worked here for less than a year, and I have been a nurse for less than 2 years, so I pretty much just always take the advice of the nurses who have worked there for a long time, and the explanation to me has always been that it would be silly to just not give it when you can borrow from someone else. Actually now that I think about it, I have even had Nurse Directors from other areas of the facility call to see if I have any of a certain med they can borrow. Thank you for this info, I didn't realize it was that big of a deal. I feel enlightened now! I think from now on I will order meds as early in advance as I can to prevent this!

[Forever Sunshine, ASN, RN]

Although "borrowing" is very common, techinically it should never be done because it's seen as stealing. In my experience, if the med is not available, you are expected to get it from the e-kit; if that is not an option, you do not give it, circle it in the MAR, and write the explanation on the back.

In reality, I have never worked at a facility where borrowing does not occur. Doesn't make it right, but that's the real world. One thing I want to add: you should never borrow; we've established that. But ESPECIALLY never, ever, EVER borrow narcs b/c on top of the stealing thing, it also looks like you are diverting.

Thats what I do. We have a narc that hasn't been in for a couple days. MD is aware. Its an insurance company issue. So I write on the back " *Name of med* not available due to pending insurance company approval."

Slam me here.. but if a med isn't in.. and you cant borrow. then you cant give it. You can't pull meds out of your ass. You can't wave a magic wand. If its 1 dose they are missing then ok. But after that then you should be letting the doctor know that you will need to hold it.

[lumbarpain, ADN, RN]

Unfortunately this is what occurred in most facilities I have worked in.....But there was one facility I did work that actually wrote you up for taking another med from anothers drawer or box. THEY COUNTED ALL THEIR PILLS, they actually numbered each pill to make sure that one wasnt missing...otherwise it was curtains for the nurse that took that pill for another patient.....it was a good system in a way but bad in another....it kept everyone on their toes about borrowing meds from other patients. If you werent working on that unit EVERY DAY....you had no idea what was right witht the count, or if another nurse had taken a med without your knowledge before you got there.....and you got blamed for it......it happened once to me and then I never did it again......so....we dealt with an outside pharmacy and other services which made it so difficult to make sure that you had everything you needed and well stocked....and also we would check off all the meds we received...but HELL...what are you supposed to count each and every pill you recieved from the pharmacy in their boxes or cards. I used to scan them all quickly with my eyes, if a pill was punched out....then back it went with the driver....then you were short in a way if you didnt make sure that med came back soon so you would nt be short. So much work so little time.

[lumbarpain, ADN, RN]

Pharmacies KNOW how much meds you should be using in a certain time frame, if a med ran out before its time.....then it wasnt delivered until its time was due. You had to wait for it. When you have alot of different nurses working differently its hard to keep track unless your Nursing supervisor or Manager is on top of them......plus having diligent, full time Nursing staff who are aware of everything going on everyday......but if you have a mish mash of per diem and part time nurses on all shifts......there is virtually NO WAY to straighten out a med problem unless you are a magician or something.