Problems in LTC- Texas

[jackiemc08]

I am a fairly new DON at a 118 bed facility in East Texas. We have a new administrator who I thought I liked, but things are not so wonderful right now. A couple of weeks ago, we had a new resident with psychiatric issues in her history. She had been living alone, but was sent to a hospital and subsequently placed in our facility by Adult Protective Services. One evening, she had an episode and got very angry. During this time, she began yelling, felt that she was being held against her will and began calling the police every few minutes. There were no medications ordered, so I called the physician on call for the nurse since I was still in the building. She refused the injection and I called the administrator. She told me to tell the nurses to hold her down and forcibly give her the medication. We did not feel that was a prudent plan of action and I called my regional nurse consultant. She was not available, so I called the lead nurse consultant for our corporation, who told me not to do what the administrator instructed. My beliefs that this was battery and chemical restraint were confirmed by her.

Yesterday, I was reprimanded by the administrator for calling the corporate nurse. She said that I should not question her directives and should have done what she told me to do.

Also, when I was hired, I was told that I was on call 24 hrs a day. The ADONs (I have 3) are on a call schedule. This administrator told me in a meeting that I would be in the call rotation from that point forward. I asked if that meant that I would not be on 24 hour call and she said "No, you are on call all the time, you will just take a call rotation, too." Last week, she announced to the ADON on call that I would be taking 2 shifts that Friday (16 hours) as charge nurse. I have not worked a floor in 13 years. I have an MSN with an emphasis in nursing administration and have been an occupational health nurse for the last 13 years doing case management and managing a clinic for a healthcare system.

I feel I should look elsewhere and now. Suggestions? I really do want to stay in long term care. Am I crazy - is this normal behavior in LTC?

[Nascar nurse, ASN, RN]

I think in your position, it is all going to come down to your administrator. I have worked with some fantastic admins and I have worked with some monster admins! The good ones I have been with would not have encouraged or even allowed us to hold someone down against their will. I may have called the physician for clarification orders, called a trusted family member to come in and intervene with resident, maybe if desperate enough.. would have even called 911 w/ intent for psych hold (hard to judge when I didn't actually see the resident).

Maybe you and your admin need to sit down with a face to face about expectations. If you can't come to agreement, you may need to start looking around.

[achot chavi]

How many beds in your facility? it may be against the law for a DON to be charge nurse

In any event, if you want to keep your job, I would be very cautious, respectful and careful with this Adm. I would document everything, keep notes and minutes on meetings, get orders like the ones you mentioned, in writing, see if it jives with your contract,

I would not be aggressive or argumentative with her, but respectfully hold your ground,

Your first mistake was in involving her in a nursing judgement regarding the difficult patient- dont do it again, handle your problems yourself and try not to involve her in nursing duties- she hasn;t a clue and cares less about your license.

You are treading on eggshells now, if you play your cards smart- things will get better,

Good Luck

[achot chavi]

BTW next time you call the regional nurse consultant ( and there will be a next time) keep the conversation objective and dont mention your Adm or anyone else, give the facts of the situation without involving names, and get advice on what you can do without implicating anyone

[txspadequeenRN, BSN, RN]

for me personally i think he is running over you. i would have a sit down talk about the responsibilities of my job just so everyone is straight (in writing) . first if you have 3 adon's then there is no reason you need to be on call 24/hr day... however saying that if you are the only rn then you need to be available 24/hrs a day but not necessarily on call. it very well may be against the rules for a don to work the floor dt the chain of command and drug diversion ..things like that. i know my current don works the floor but my former don's would not for this very reason. someone with more knowledge on the subject can fill you in better on this.

this is why i love my don..she has no trouble whatsoever about telling the admin to say in his office and that she is running the show when it comes to the nursing side...

stand up for yourself and you position...but be ready to look for other employment it he cont to be the backside of a horse...know what i mean

[CapeCodMermaid, RN]

You were right...administering any IM against a patient's will is assault and battery at the very least. I had an ED like the one you describe. She was always sticking her non clinical nose into my department. She thought she was clinically minded because before being an ED she was a diet aide! I had no trouble reminding her that I was the one with the license which had the RN on it. It can be horrible if you can't count on your administrator. I worked in a really tough building once...5 or 6 DPH reportables every week...had the BON and the DEA in the building..union troubles..you name it,we had it. BUT, my ED and I worked as a team so even when it was horrid, we knew the other one was right there for us. Made a huge difference.

[Valerie Salva, BSN, RN]

Short answer:

Run, Forrest, Run!

[jackiemc08]

We have 118 beds. I have applied for every job I can find locally. I have an MSN with an emphasis in administration.

My husband had a severe traumatic brain injury 4-1/2 years ago and after that I had this feeling that I needed to do something other than occupational medicine. I was certified in case management as well at the time and had to use all of my knowledge to help him. I ended up doing most of his therapy myself because no one else seemed to be helping him. I knew that if we had the struggles then others with no advocates must be just drowning. So, I started working as a weekend RN supervisor at a nursing home right around the corner from my house. I loved it and wanted to make a difference for others, so I applied for this job as DON and got it. I had so many high hopes and have grown to love the residents. It will be so hard to change, but I know I must if I value my license.

Thanks for the advice about the nurse consultant. I just have an open and trusting nature and am learning the hard way that I can't be like that. I welcome all the advice I can get from those that have been doing this a long time.

[debRN0417]

Over 60 beds- the DON cannot serve as a "charge nurse". Why in the world would the DON be a charge nurse with all those ADON's floating around? The Administrator of the facility should be aware that what you were asked to do was not responsible or professional- downright borderline criminal. You need to have a meeting with your Administrator and ya'll need to hash out some expectations. You have a call rotation schedule, that is what it is, but you may have to be available in case the on call person needs back-up. You need though, to have some time away from the mess, because it is not good for the mental health if you don't have a small respite every now and again.

Again I think it is messed up that the DON works the floor when you have other nurses who according to the call schedule, should either find help, or work the floor. I do not mean to say that the DON may never have to work the floor, because in an emergency that may be the case, but you should not be scheduled as a charge nurse....sounds to me like there needs to be an outlining of the expectations, and rationales, and then you need to decide if that is what you want to do. I would also get it in writing so that the Administrator can't suddenly "change" the rules and leave you in a mess....Your administrator sounds to me like she needs some studying on regulations and resident rights....

[noc4senuf]

That is true according to Federal regs, a DON can not be charge nurse IF your bed count is over 60.

[jackiemc08]

Thanks everyone. I left that job and have another one at a much, much nicer facility.

[debRN0417]

Good for you