Advise needed for a PA who breaks the rules

VegRN · Jul 23, 2007

I am assuming there isn't approval by the director for the med.

You COULD give the med and document the conversations you had with management and the policies but, bottom line is, you know better and there also is a policy against it. How would you defend yourself in front of the BON if you were being investigated for this? I really don't think you could.

I would ask the DON what to do in this situation r/t whether to give the meds or not. Obviously you need a resolution to this situation before management decides to get their act together. Also tell the DON that if they tell you to give the meds and you do give them, you will be noting that conversation in the chart. I bet the DON won't be telling you to give them after you say that! If it were me, I wouldn't give them.

I would tell the PA that you are not going to administer the med per policy xyz, document it as such in the chart and note the policy and what you said to the PA and insist on another med, also note the PA's response. If there is an actual policy on this, how can the PA just ignore it? The inmate is still getting NSAIDS for more than 10 days no matter how you slice it. You know better than to give the med and that is why you are not comfortable with it. Nurses are always responsible for meds they give. It doesn't matter if their is an order for it, you are still responsible. Would you give a dose of 20mg IV MSO4 to an 85# opioid naive pt just because a PA and your DON said to do it. No, you wouldn't, and that is where nursing judgment comes in. Don't do something you know isn't right.

You would think that management would be more aggressive with disciplining this PA since there have been several lawsuits r/t this. Management having trouble attracting medical staff? Ar they afraid to lose him? And how can you not have a Dr that you can contact? A P.A. is a physicians ASSISTANT so they must have an Md to cosign their assessments and orders. They cannot practice alone unlike N.P's. There has to be an Md that you can contact about this. Doesn't matter if they are or aren't in the building, you should be able to contact them, at least by phone.

I wish you luck in this situation. The clincher for me is that there is an actual policy against it. I wouldn't do it.

Icare4u2 · Jul 23, 2007

nope , i wouldn't do it either. it's that whole policy thing and the fact that you would be responsible if you do give it. sounds like someone thinks a little too highly of himself. good luck!!

JailRN · Jul 27, 2007

document, document, document---(protect YOUR license,) and send copies of everything all the way up the chain. Sounds to me, too, that somebody is a little too arrogant. Wait until after the first lawsuit THEY are involved in--that usually changes their minds about circumventing policies. I don't envy you. Just know, that, usually, people like that don't sitck around long. Can you hasten their departure? I mean, if everyone is truly fed up with 'Jr. Doc' perhaps a dose of brownies with exlax will 'encourage' him to leave. (hhhmmmm--just kidding) Let us know what happens.

TrudyRN · Aug 3, 2007

Also tell the DON that if they tell you to give the meds and you do give them, you will be noting that conversation in the chart.
Keep it out of the chart. Plaintiff's attorneys love arguments between staff. Give them no ammo.

TrudyRN · Aug 3, 2007

There is a quiet way to do this.

Tell the PA you cannot, in good conscience, give the med but that you will gladly hand him the med bottle and he can administer it himself. Same as you would do with a doc's order that you could not, in good conscience, give.

Or, even more quiet - just find the bottle empty all the time. Or lost. Or the inmate just, somehow, never comes to med pass. I don't recommend any of these. But when your idiot bosses are too namby pamby, too lazy, too inexperienced or uninformed to take the reins and actually get you out of the fire, well, you have to protect yourself. You respect your boss but I'm not sure why. He or she is just sidestepping the whole issue and dumping the responsibility right back on you, where it does NOT belong. Go over her head. Call the medical director yourself. Call the state Board. Report the PA and his MD overseer for lack of proper supervision. Contact whoever is next up the line from your Sup. This is so ridiculous. Good luck. Look for another job.

I guess the best way is to gather all of your fellow nurses together and write up a petition about this and present it to your boss. Occupy her office until she gets you an acceptable answer.

TrudyRN · Aug 3, 2007

OK, I reread your thread. Here are some responses.

[quote=uraqt2;2313468]I need some advise. We have a new PA who has never worked in corrections and wants to practice as though he is still practicing in a clinical setting. He has managed to insult How? Does any of it rise to the level of creating a hostile workplace or harrassment of some kind? every nurse and refuses to accecpt any advise on handling inmates or following policies. The not following policies is the major problem that we're having. For example, we no longer give long term NSAIDS due to the fact that we've had several law suits (and lost) due to complications from NSAIDS. Policy states that NSAIDS cannot be given for more that 10 days without the approval of the director. Our PA has found a way around this policy by ordering these meds for 10 days with refills x 3. I don't see how this is a way around policy. Even if it's a refill, it's still more than 10 days.

When he is confronted by this, he develops the who are you to question me attitude. And your response should be that we nurses are the ones whose licenses and livelihoods and consciences and ethics are at stake, therefore, we must refuse to follow this order, as it violates policy.

We have no onsite Dr. to go to regarding his complete disregard of policies so we have resorted to going through our chain of command. The charge nurses and DON have spoken with him numerous times with no avail. Here is the real problem. Your bosses are not handling this correctly. They should have gone immediately to the PA's direct boss and gotten a different policy, in writing, before the sun set that very day. They are throwing you nurses in the trenches to the wolves. I have recently spoken with my DON and advised him that I'm ready to go to the director myself and was told that he (Who is "he"? Your DON or the Director?) was aware of the problems and is working on them. He futher told me that I needed to let him handle the situation. I think you are letting him handle but he is handling it ineffectively and much too slowly. What are you supposed to do in the interim? Your DON and Director are safe in their offices. You are on the front battle line. Now I'm left with do I refuse to give the meds for more than 10 days per policy or do I break policy because I have other orders on the chart? Having other orders on the chart is irrelevant. I don't want to break my chain of command as I do respect my supervisor, I'm just at my wit's end. Any advise is appreciated

Just curious - how long does the break between the 10 day periods have to be? Maybe this is your graceful "out". Maybe a 24 hour period off of them is long enough? Drag your feet about re-ordering the med if you have to.

Also, are you giving the NSAIDS with food? If not, you should institute that right away.

To save your job, don't cross your boss. Pray, though, that he quickly leaves your life, maybe gets moved somewhere where he can't harm patients or other nurses. Bosses like this are so frustrating. How'd he get his job anyway? Old friends in high places?

uraqt2 · Aug 7, 2007

ok, i reread your thread. here are some responses.
[quote=uraqt2;2313468]i need some advise. we have a new pa who has never worked in corrections and wants to practice as though he is still practicing in a clinical setting. he has managed to insult how? does any of it rise to the level of creating a hostile workplace or harrassment of some kind?(he has said things like "you just don't want to delivery these meds cause you're too lazy", "what you're eating again don't you think you could miss a meal and get more of your work done" yes, i have concidered hostile work environment but i would like to try every avenue before filing investigation. i think that working as an adult ultimately gets you farther and i like to treat people how i would want to be treated.) every nurse and refuses to accecpt any advise on handling inmates or following policies. the not following policies is the major problem that we're having. for example, we no longer give long term nsaids due to the fact that we've had several law suits (and lost) due to complications from nsaids. policy states that nsaids cannot be given for more that 10 days without the approval of the director. our pa has found a way around this policy by ordering these meds for 10 days with refills x 3. i don't see how this is a way around policy. even if it's a refill, it's still more than 10 days.(right, but the pharmacy who fills our meds doesn't catch that the order is meant for 30 days they interpret it as 10 days every month times 3 months)
when he is confronted by this, he develops the who are you to question me attitude. and your response should be that we nurses are the ones whose licenses and livelihoods and consciences and ethics are at stake, therefore, we must refuse to follow this order, as it violates policy.(i usually force my charge nurse to handle the situation before i say something unprofessional. they know me well enough that when i reach this point intervention needs to take place cause i can be pretty harsh)
we have no onsite dr. to go to regarding his complete disregard of policies so we have resorted to going through our chain of command. the charge nurses and don have spoken with him numerous times with no avail. here is the real problem. your bosses are not handling this correctly. they should have gone immediately to the pa's direct boss and gotten a different policy, in writing, before the sun set that very day. they are throwing you nurses in the trenches to the wolves.(i agree.) i have recently spoken with my don and advised him that i'm ready to go to the director myself and was told that he (who is "he"? your don or the director?)(the don had gone to the director with this problem and they were working on a solution)was aware of the problems and is working on them. he futher told me that i needed to let him handle the situation. i think you are letting him handle but he is handling it ineffectively and much too slowly. what are you supposed to do in the interim? your don and director are safe in their offices. you are on the front battle line.(agreed) now i'm left with do i refuse to give the meds for more than 10 days per policy or do i break policy because i have other orders on the chart? having other orders on the chart is irrelevant.(to some point. it's just a problem that i have cause i have been accused of not following orders in the past and have had to go through the whole institutional investigation process. which i might add that i was cleared of all charges.) i don't want to break my chain of command as i do respect my supervisor, i'm just at my wit's end. any advise is appreciated
just curious - how long does the break between the 10 day periods have to be?(30 days) maybe this is your graceful "out". maybe a 24 hour period off of them is long enough? drag your feet about re-ordering the med if you have to.
also, are you giving the nsaids with food? if not, you should institute that right away. (we only pass meds twice a day per policy so what we do is give the days worth of meds and instruct the inmate to take with meals. we can get away with this cause policy also states that nsaid's can be kop'd x 4 days.)
to save your job, don't cross your boss. pray, though, that he quickly leaves your life, maybe gets moved somewhere where he can't harm patients or other nurses. bosses like this are so frustrating. how'd he get his job anyway? old friends in high places?

thank you for all your advise it is greatly appreciated. i have sent you a personal message also.

CheyRN · Aug 7, 2007

The not following policies is the major problem that we're having for example we no longer give long term NSAIDS due to the fact that we've had several law suits (and lost) due to complications from NSAIDS. Policy states that NSAIDS cannot be given for more that 10 days without the approval of the director. Our PA has found a way around this policy by ordering these meds for 10 days with refills x 3.

I have many question regarding your problem. 1)Do you work in a jail or prison? 2) Do you actually HAVE a written policy stating that you are not to be giving more than 10 days of NSAID's? By continuing that order X3, he is violating that WRITTEN policy and by taking that to the warden or his rep. you might get some action. 3)"NSAIDS cannot be given for more that 10 days without the approval of the director" How is that approval documented? It should be documented with each and every "10 days X3" order. If it's not then the both the PA and the director are not following policy and I doubt he wants to join that PA in the unemployment line. He may put a stop to this practice if you call the director everytime you get an order like this and insist he co-sign said order. What ever you do, just make sure you have a policy IN WRITING to back you up or you will be swirling the bowl all by your lonesome:o

uraqt2 · Aug 8, 2007

In response to your questions I work in a prison and yes we have a written policy. It is documented by use of a non-formulary. The non-formulary is faxed to the director and if approved nursing can then start the medication. If it is disapproved the order is D/C'd. Whether approved or disapproved a copy is placed in the chart. As an update though I have heard rumor that our PA has been offered another position. Don't know if it's true as he hasn't resigned yet, but time will tell.