New job: "Don't worry about following the MAR" & other scary stuff

MB-mom.RN · Sep 16, 2013

-you will absolutely need to pass all the night meds at once for the most part, esp being on a unit w/ demented patients, i was lucky if i could get some of them to take meds ONE time a night, def wouldnt of gotten them to take meds THREE times... better to get them in when you can. (not to mention the time problem, if you try to give all the meds exactly as they are timed you will never get done)

in nursing school they taught us the "nclex way" to do things and the "real way" you're actually gonna do things

ak2190 · Sep 17, 2013

In all honesty, nothing sounds terribly scary other than the not wearing gloves. It's all pretty routine in LTC, and in fact, it's quite impossible to do the job any other way. The only things I'd be wary of would be pulling my meds ahead of time and not wearing gloves.

LaRN · Sep 30, 2013

If you have trouble remembering the meds that you pre poured, write the meds on a tiny small piece of paper, and fold it small enough to fit in the medicine cup.

and none of the things you mention here are that bad. waking people up for routine meds makes no sense.

on insulin: unless a nurse has very poor vision or she's incompetent, she should be able to draw up the correct amt.

saying you are worried about losing your license is a bit dramatic for the situation. it may not be a strict adherence to the rules, but it isn't a reckless disregard of standard care either.

but wear your gloves. or wash your hands very very often

joanna73, BSN, RN · Sep 30, 2013

Insulin is definitely one medicine that should only be administered by the nurse who poured it. In fact, some facilities require a second witness for insulins.

LaRN · Sep 30, 2013

I think it's extremely frightening that so many folks here think it's A-OK to have three days/nights of orientation for a new grad! and then expect that to be a safe, critical thinking nurse. OP do yourself and your education a favor and try to get a hospital job.

you must scare easily. she isn't alone, there are 2 other nurses in the building. and even if not, it isn't an acute care unit, its LTC, the most difficult thing is the repetitiveness and med passes that take forever. it's pretty cut and dry, just use the MARs.

and she had 20 patients :dead:

patientsafetygeek · Oct 1, 2013

I'm disappointed that there seems to be such laxity with LTC. I understand that systems and situations as they are contribute to it, but it doesn't make it right or safe. Are there guidelines for LTC that give scope of standardized expectations for these items?

The medication time practices may align with what patients do at home anyway, but keeping things out/locked up til later/ etc just set you all up for errors. Especially the whole insulin thing...that's a high alert medication no matter what. Trying to educate patients and families on that with transition to home so I see this concern extending to the community. Can some sort of standardization occur with doc orders and patient schedules that make this doable and still safe? I can also see assessments more or less by exception (I would probably be doing a focused assessment based on PMHx or current status).

I recall doing home care on a patient that had crazy high sugars. A new regimen was started in the hospital, but it got lost in follow up and transition. She's having symptoms at home and she and her roommate just call them "spells" that pass and nothing is done about it. What is that? A potential 30 day readmission, cost, and negative outcomes for the patient. Also had a patient restart Coumadin and no follow up INR for three weeks when I went to visit. Really? All transition and communication issues.

I don't have insights on LTC and so cannot speak to what can be done to make this better. I believe all of you have the power to speak up and create a system, based on guidelines, that can be modified for your situation and safety needs. One size does not fit all...so how do you make it fit for your facility?

If regulatory demands haven't fallen on LTC yet (as much as the hospital), it will. It's just a matter of time and prioritization. This will sound corny, but you guys can change things and make a difference...I believe that. You're the experts in LTC.

LaRN · Oct 2, 2013

Insulin is definitely one medicine that should only be administered by the nurse who poured it. In fact, some facilities require a second witness for insulins.

right. i wouldnt give an injection of anything that someone else prepared. esp insulin b/c there are different types.

I know its ideal to get another nurse to verify insulin dose, but I think I've seen this done maybe once since 1996. .

AngelicDarkness · Dec 8, 2013

I had a family member tell me to lie to Mom about her meds:(

OrangeSlushie, RN · Dec 17, 2013

It is common practice to give all evening meds at the same time it seems. What I'm always left wondering, is why not change the med times? Clear it with the MD and then make the time you like to give them the official time!

I'm a day-shifter who occasionally works over into evening. After it's officially evening shift, I run into this constantly: "Only two pills? Where are the rest of them?" During the day I follow the MAR faithfully and never have any trouble, no matter what unit I work. But evening, it's a totally different story. And then the nurse coming in to relieve me makes me feel like a chump for not passing all of their meds.

If you know these patients won't take their pills after they go to bed, why not change the administration times?!? Sorry, it's something I find very frustrating. I'm a rule follower by nature, so giving somebody their 8pm meds at 4pm just feels wrong. Change the times or give them correctly. And if the MD doesn't want the times changed, should you really be giving them early?

CrossCountryRN2008 · Dec 17, 2013

If you have a two hour window to give meds you can give 1800 and 2000 together. If it makes you uncomfortable to give all meds together as the Dr or NP for orders to change med times

Gabby-RN · Dec 18, 2013

Thank you all for the advice. Quite a bit of it makes sense to me about the med times and insulin and such. However, I will be resigning from the position tomorrow. I talked to my former clinical instructor today about my worries, and she agreed. Her advice to me was to quit immediately. I do not feel comfortable signing off on the e-MAR that medications were given when they weren't or charting things that were not done/assessed. The charting IS a full assessment, including whether their bowel/lung sounds were normal, what their pupil reaction is, etc. I will NOT chart something I have not done/assessed. I will NOT pull meds, put them in a drawer, sign them off, then give them later. I understand where some of you are coming from, and I understand this is accepted as the norm in LTC, but I feel like it is a ticking time bomb for medication errors, and I do not want to be a part of it. Overall, I feel uncomfortable with this facility, I do not feel like I am able to ask questions without just being waved away with a "You'll be fine, don't worry." Again, thank you for your advice! I do not want to come across as a rude/unappreciative person. I know I have to start my nursing experience somewhere. But I cannot work at this facility.[/quote']
I think wherever you go next you should insist your orientation be extended if you need more time, particularly if it is less than a month. LTC facilities can get away with 3 days of training for an experienced nurse but they should expect to provide more to a new nurse.
My 1st job was at a ltc facility and much of what you described is common. I always gave my night meds at once although I never prepared them in advance I charted when I gave them. Our pharm policy book gave a 2 hr window for daily and bid meds, 1 hr window for more frequent, and a 30 min window for insulins and anticoags. There were times meds weren't given on time and that was ok as long as a reason was charted. When I switched to day shift I made every effort to get all the med times consolidated for the long term patients.
As far as assessments, my charting was by exception, I could simply check that each system was wnl or chart if there was a change. If a pt is having daily bowel movements they most likely have bowel sounds. If a pt has good color is breathing regularly, doesn't look winded or get sob when transferring to the toilet, isn't coughing, etc. then there lung sounds are probably at their baseline. I always listened to the lungs when the pt was receiving nebs or was sitting up in their chair while I made small talk about what they ate today or how they slept etc. I would check some pts pulse while lightly touching them as they told me a story (also feeling their body temp at the same time). It would make them feel good and show that I cared while also completing a task. It only takes a minute and is easy enough to do while you are doing something else. In ltc these pts aren't acutely ill and don't require a full head to toe every 8 hours. I know this was a difficult realization for me fresh out of school as it seems to be for you. You will find ways to work an assessment into other tasks.
I think ltc facilities expect alot out of nurses and it can be too much oftentimes. I did learn so much and truly believe working ltc made me a more efficient nurse with great time management skills and that is how I marketed myself when I interviewed for my first acute care job.
I think many of the previous posters gave you some good advice. In your next job I hope you are able to speak up and make changes so that you can feel comfortable with your practice. Don't be afraid to ask the doctor if you can change med times, let them know if a pt likes to go to bed early, or if they sundown and refuse meds after a certain time etc. Nurses are the eyes and ears of doctors. More than likely they will say no problem or let you know why they cant change the time.
Good luck! I hope you find a job that you love very soon.

ArtClassRN, ADN, RN · Dec 18, 2013

Here is my list of things that worry me:

#1: Not double checking insulin. My preceptor told me not to worry about doubling checking. "We just draw it up & give" since there are lack of nurses around.

We don't double check insulin on my med surg floor. We double check IV med drips.

#2: Not following the MAR. There are patients who get meds a 1800, 2100, and 2200. The patients...

In many cases, there is nothing wrong with moving medication times around patient needs. I would chart when I gave them and not mess around with pulling them early.

#3: Charting "the usual". My preceptor fills out the charting with the patient's usual, sich as "active bowel sounds", "no adventitious lung sounds", etc. I was told not to worry about assessing them & was given the "answers" to fill out their charting. I have been there a total of 4 days & never once seen anyone assess the patients heart/lung/bowel sounds! With the crazy number of patients & their medications, I only have an hour that I could spend assessing them anyways!

Chart what you assess and stop worrying about what others do.

#4: Not wearing gloves for anything! I've seen me preceptor & other nurses draw accuchecks, give insulin, and eye drops with no gloves on! She told me not to worry about it (I did not listen to her, I refuse to give injections or draw blood of any sort without protection!)

Again, you can practice however you wish. I give injections and eyedrops without gloves all the time. I wear gloves for draws of any kind.

So adding all this to the fact I am brand new, on my own, and no one to ask questions to, I am pretty sure you see how uncomfortable I am. I cried the whole way home from my first shift...

That's basically SNF/LTC for you. Many of us have worked in them. Do the best you can and get the heck out.

I really think it is in my best interest to quit, but my husband is worried because I need a job & he doesn't understand how bad these things are. I need advice, please!!

Do the best you can and find another job as soon as you can.