Am I wrong? Is this legal?

[bossfrog]

I have been a psych nurse for 6 years and did some traveling for a while. At my current job in Indiana (which is a permanent job, not travel), they have a practice that I'm not comfortable with and I can't seem to find anything definitive to confirm what I believe to be true even though I'm fairly certain I'm right. What they do here is on night shift, when a referral comes through, they expect the nurses to make the decision whether or not to admit a patient. If the criteria is clear (such as psychosis or suicide attempts) then they want us to get consents and give the referring agency the go-ahead to send the patient without calling the doc. None of the 5 psychiatric facilities prior to this one ever did this. Even when the criteria was clear, they ALWAYS called the doc for the decision to admit. Now the understanding here is that if it's a clear case, the doc will sign off on the admit orders. But the question I have is what if a patient gets admitted that the doc says he wouldn't have accepted? You can guess who would get the blame.

I have refused to do this, with the support of some peers and the scorn of others. RNs do NOT have admitting privileges to my knowledge and there can be no such thing as a standing order to admit non-specified patients. One of the unit secretaries actually wrote me up for refusing to make a unilateral decision on a patient! Am I way off base here? Is this common practice and this is simply the first time I've run across it? Most importantly, is it even legal? Should I report the write-up to the Nursing Board? Hell, should I report the hospital itself and start looking for a different place to work?

[Davey Do]

It sounds as though you're right-on with your perspective and beliefs, bossfrog.

And I wouldn't concern myself about a non-professional staff member writing you up over a professional decision. That's ludicrous!

Whenever I have had such a problem, I objectively document the situation, allow administration to have their say, and if the situation wasn't rectified, have gone on to report them to outside agencies.

Keep on keeping on, and the very best to you bossfrog!

[bossfrog]

Thanks Davey. But what are those appropriate outside agencies? And the write-up really just pissed me off more than anything. My DON said if I'm not comfortable bringing in a pt without talking to doc, that's fine. But the administrative people are the ones insisting we do this. They say the doctor's wife (she owns the hospital) complains when the doctor doesn't get enough sleep. So administration doesn't want him called. Either way, I'm sticking to my guns.

[Davey Do]

You're welcome, bossfrog.

Public Health, as an agency to contact, comes to mind. Maybe Medicaid and/or Medicare.

We have the same problem with a psychiatrist who won't return our calls on MNs. The psych director has instructed us to just call her and she will reach the psychiatrist via a "backdoor number".

Once, when a patient attacked me, that was totally behavior, and the psychiatrist wouldn't return our calls, we contacted her. After not hearing back from either of them after numerous attempts, the director finally called us back, apologizing that she had fallen asleep. She apologized profusely. I gave what for and she gave us her husband's phone number.

"Oh?" I asked, "If we can't get a hold of the psychiatrist, and you don't answer the phone because you're asleep, we should call your husband? So he can wake you up, so you can wake up the psychiatrist?"

"Let's take that plan a step further!"

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Sheesh!

Good luck, bossfrog!

[sallyrnrrt, ADN, RN]

When I worked ER, several facilities.......And we had psyc inpatient referral.....the Psyc.RNs screened for appropriate admission , this was facilitated by the patient having mental health warrant, and ER physician's recommended. I do not know for sure, but there may have been psyc standing orders?..... The mental health warrant, in Texas facilated 72 hr hold...the patient being assessed by Psyc Physian the following am ( in Texas). Also in Texas, during a night admission, the ER physician wrote admitting orders, that were just initial orders pending attending eval....

However; DaveyDo has extensive experience........I value his recommendation.

[Davey Do]

That's pretty much the way it's done here also, Sally. The ERP can admit to the psych units and the psychiatrist follows up the next day.

99% of the ER psych admissions are kept for inpatient treatment, which is a lot more than the medical side for ER admissions.

[Crush]

My facility, only a doctor, regardless of the time of day or night can admit a patient period. Including the psych unit. The ERP here contact the on-call psychiatrist for the approval to admit.

Bossfrog, you are spot on with your thoughts. I agree with DaveyDo, don't sweat the write up (although it would irk me too). You are doing right.

[Nurse SMS, MSN, RN]

So a physician's WIFE is calling the shots??? OMG. Find another job. Seriously.

[elkpark]

In my experience and understanding, there has to be a physician (or other provider) with admitting privileges, whether that's an attending psychiatrist or an ED doc (or another physician/provider), who writes admitting orders. The hospital is going to be in deep doo-doo someday when something dreadful happens to someone on the unit during the night and there are no admitting orders on the client.

I've worked in plenty of settings in which the admissions orders and initial H&P were done by an ED or internal medicine doc and the client wasn't seen by the psychiatrist until the next morning -- but some physician/provider saw the person, examined her/him, and wrote admission orders.

And I agree with not.done -- what is this, some kind of mom 'n pop psych hospital?? I wouldn't be touching that with a ten foot pole.

[bossfrog]

Elkpark:

Your first paragraph above is exactly right. When patients come overnight, the admission orders (PRNs, vitals, labs, home meds, etc.) aren't gotten until morning. That itself isn't generally a problem and isn't uncommon. The problem is that there are no PRE-admission orders, which is where the order to admit or deny a referral is usually issued at almost every other hospital. That needs be be gotten directly from doc before giving the green light to transport the patient. That order is on the same form as the rest of the admit orders. So there is no order written for a patient to even be on the unit until those orders are gotten around 0530, according to how administration wants it done. It IS going to bite them in the ass someday.

What kind of brought this to a head was a new process apparently started last night. The unit secretary put a referral on my desk and said, "You have a 15 year old girl coming soon."

I asked, "Did you go ahead and call Doc or what?"

She said, "No, I approved it."

I just looked at her and said "Are you kidding me? I didn't even look over the labs or anything to verify her medical condition." [she's NOT a nurse, BTW. She's a CNA.]

She told me that administration was getting tired of some of us nurses refusing to bring in patients over night(without calling doc), so they approved for her to make the decision. I guess if they're going to do that then I'm going to wake up Doc anyway and get the order before the patient arrives. I won't have a patient on my unit without orders! Then if he denies the patient for whatever reason, our unit secretary can call the ambulance service and tell them to turn around.

I told the secretary she has no legal right to make that decision. She said it was a change in their policy. I told her the law trumps policy and she's just too dumb apparently to get that.

I was just beside myself and that's when I made the original post on here. I'm pissed because I like everything else about my job. And the problem isn't the doc. It's the pressure his wife (the owner) puts on administrators (who are all business people, not medical people) when he gets woken up. But because administrators want to push the limits of what is legal, I might have to quit.

As for being a "mom and pop" hospital, no. They're the largest privately owned, free-standing psych hospital in Indiana. So there is no ERP to write admitting orders here. It must be the psychiatrist.

I feel like this crap needs to be reported somewhere but I don't even know where, or even if I should. I don't want to hurt my staff that I work with.

[JKL33]

I feel like this crap needs to be reported somewhere but I don't even know where, or even if I should. I don't want to hurt my staff that I work with.

Not to be overly-dramatic but I kinda think a CNA "accepting" a patient for admission is one of the more insanely wrong things I've ever read here.

There is no patient hand-off or proper transfer of care taking place. Absolutely none. Not to mention everything else...

[bossfrog]

Not to be overly-dramatic but I kinda think a CNA "accepting" a patient for admission is one of the more insanely wrong things I've ever read here.

There is no patient hand-off or proper transfer of care taking place. Absolutely none. Not to mention everything else...

Yep. You're right. I mean, yes, the doc's name always goes on the order form in the morning, but that's NOT the way it's to be done.

Just to clarify, in case it hasn't been to this point, I personally NEVER do this. When a referral comes to me I do not accept them until I can talk to the doc. If I can't get him on the phone, the patient sits tight until I finally do get hold of him. That's actually part of the flack I got. They said I let a patient sit in the ER somewhere for 6 hours without giving them an answer. And I told them that's how long it took to get the doc on the phone. I mean, in the end, what are they going to do? Oh, right... they gave that decision to a CNA.