Asked to break the law

Published

Ok, so maybe that wasn't the most objective thread title, but it is certainly the most honest.

I am already struggling with the "personality" of my new job working as the sole RN at a plastic surgery center, but we have reached a new low. I need to get opinions on whether I need to start job searching, trying to change things or????

Amongst many other tasks, I circulate. By law, in my state (Texas), only RNs can circulate unless they are "directly supervising an LVN" to circulate. The other day I was ordered by my surgeon to go to lunch during a case and be relieved by the LVN. I protested and explained. She said I was wrong and made me leave. (Being an anal-retentive RN, of course I documented every aspect of this event.)

So yesterday I asked our office manager, who has worked with the surgeon the longest, the best way to approach her with my concerns. I told the manager I did not want us to get shut down or sued. She not-so-politely "informed" me that I was wrong, and that according to AAAASF (the surgery center accrediting body) we were fine, and that the surgeon's husband (also a surgeon) sent his RN away all of the time.

I was not trying to start a fight (honestly!), but I felt like this needed to be addressed. (I mean, I work with mostly nice enough people, but I am not giving up my license for them.). So I emailed the manager a copy of the state health code and law stating all of the facts.

No response. Tumbleweed blows by.

The rest of the day was short and snappy comments, but NO emails regarding anything whatsoever were returned, some of which were crucial to running this place.

Should I take this to be indicative of some kind of immature corporate culture? Should I let it go for now? What did I do wrong?

HELP

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Call your BON and see what they say about it.

"Directly" supervising an LVN is subjective-

I would be most concerned that the LVN is putting their license at risk, as it is a "rumor" that LPN's "work under an RN's license" they have their own to protect.

Medical offices are strange things--the MD can have anyone do anything and it is on the MD--

But do check with your state BON and see what they say regarding this. Also, look at the LVN scope of practice in your state. In mine, an LPN can do whatever a facility allows them to and shows competency in, except for clinically directing RN's. And since you are the only RN in the facility, clinically directing other LPN's or UAP's is something that I would think would be covered under scope. But check and see.

Make sure you and the LVN have .

This is not meant as legal advice per TOS, but if the LVN is taking care of patients without your direct supervision, however, then can't "circulate" it doesn't make sense.

FAQ - LVNs Supervison of Practice.

This specifically states that an LVN can also be supervised by other entities than an RN, including an MD. But be sure to call the BON and ask.

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How are you breaking the law by leaving during a surgery? Is there a law in your state that every surgery needs to have an RN present?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
How are you breaking the law by leaving during a surgery? Is there a law in your state that every surgery needs to have an RN present?

That is what she said....

By law, in my state (Texas), only RNs can circulate unless they are "directly supervising an LVN" to circulate.

OP I would call the BON and see what the definition means by.....direct supervision...... means. I would also ask you if the have any advice. If the BON state you must have direct vision then you need to stand your ground or find another position....I personally would not go against the state practice acts...but I would clarify them first.

Using Jades resource......FAQ - LVNs Supervison of Practice.

the NPA and rules are silent as to the proximity of the licensed supervisor. There are many factors to be considered in determining how quickly the licensed supervisor needs to be available to the LVN. Factors to be considered should include:

(1) the type of practice setting;

(2) the stability of the patient’s condition;

(3) the tasks to be performed;

(4) the LVN’s experience and

(5) any laws and regulations that apply to the specific practice setting.

The proximity to the LVN’s practice setting and the type of licensure of the licensed supervisor should be determined on a case-by-case basis with input from the LVN and his/her licensed supervisor.

The appropriate licensed supervisor must be accessible to the LVN at least telephonically or by similar means. To illustrate, compare the LVN who performs routine nursing tasks or nursing tasks learned through ongoing continuing education (such as intravenous therapy) with a LVN who performs a delegated medical act (such as Botox administration).

These are different situations and will differ in who (RN or physician) is appropriate to supervise the LVN as well as the proximity of the licensed supervisor.

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Im thinking that If the physician is there you have nothing to worry about. and even if you do have to supervise her, I don't think you are responsible for making sure that there is an RN present to supervise her at all times, you just have to supervise her during the times you are assigned to do so.

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A CRNA is supervised by an anesthesiologist, but that doesn't mean the MD has to be in the room with the CRNA the whole time. An RN supervises the work of a CNA, but that doesn't mean the RN has to be in the room every time the CNA is getting vitals. You just have to make sure the LVN followed protocols and documented correctly.

If it were the way you are describing, they wouldn't even hire LVN's because it would be doubling up resources (might as well only hire RN's) and not saving them any money!

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Specializes in Critical Care, Education.

Hmm - just took a look and the Tx law is very specific (Government Affairs ) It requires "direct supervision of a qualified RN circulator". There's no stipulation that the surgeon can do this... and I believe that this would also be a violation of one of the important checks and balances that preserve patient safety in an OR. The surgeon has to focus on her/his job - not multi-task by supervising the circulator as well.

I always like to presume good intentions when approaching any conflict, so I suggest that the OP should discuss this with admin & provide them a copy of the legislation. They are probably not be aware of the specificity of the law. Let's face it, physicians don't pay any attention to 'nurse stuff' unless they are forced to do so.

A bit of context may be helpful. Texas still has "permissive licensure" which allows physicians to delegate just about anything to anyone that they choose... as long as they assume responsibility. It used to be common practice for surgeons to have their own private 'scrub nurse'... who may not have been a nurse at all. Luckily, most hospitals have put a stop to this but it is not "illegal".

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TEXAS

ADMINISTRATIVE

CODE TITLE 25. HEALTH

SERVICES PART 1.

DEPARTMENT OF

STATE HEALTH SERVICES

CHAPTER 133.

HOSPITAL LICENSING

SUBCHAPTER C.

OPERATIONAL

REQUIREMENTS

AS AMENDED BY HB 1718 (2005):

Sec, 241.0262. CIRCULATING DUTIES FOR SURGICAL SERVICES

Circulating duties in the operating room must be performed by qualified registered nurses. In accordance with approved medical staff policies and procedures, licensed vocational nurses and surgical technologists may assist in circulatory duties under the direct supervision of a qualified registered nurse circulator. (Eff. September 1, 2005)

Sec.A259.003.AASUPERVISION OF SURGICAL TECHNOLOGISTS. This chapter does not repeal or modify any law relating to the supervision of surgical technologists

Under supervision of RN

RN Circulator Supervision

 Circulator role

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Sec, 241.0262. CIRCULATING DUTIES FOR SURGICAL SERVICES

Circulating duties in the operating room must be performed by qualified registered nurses. In accordance with approved medical staff policies and procedures, licensed vocational nurses and surgical technologists may assist in circulatory duties under the direct supervision of a qualified registered nurse circulator. (Eff. September 1, 2005)

Assisting means, well, assisting the person who is doing the job. The RN. I agree, get this reinforced in writing from the BoN. Ask them to specifically address the idea of your going to lunch and leaving the LPN the only circulator. Mention the idea that physicians do their own jobs, not ours.

And it may be that even though they aren't talking to you about this at work, they may very well be talking to their higher-ups and consulting the BoN themselves. Wait to see what happens while you are awaiting your own BoN opinion, and then think about what you want to do next depending on what it says, and your management says.

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Specializes in Med/Surg, Ortho, ASC.

Despite apparently being in the right, I think your employment at this facility may shortly be coming to an end. Those who rock the boat in small facility (even when they rock it for the right reasons) rarely last long.

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I still don't know how the RN who is not there is breaking the law. Maybe the surgeon is. the LVN may be doing stuff outside his/her scope. But, how can you be breaking the law if you are not there?

I work in an ER. If I go on a lunch break and a CNA starts an IV, or an LVN does something out of their scope while I am eating, I haven't broken any rules or laws.

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Specializes in ER/ICU/STICU.
A CRNA is supervised by an anesthesiologist but that doesn't mean the MD has to be in the room with the CRNA the whole time. ![/quote']

That statement is entirely false. CRNA's are independent providers. Supervision and medical direction are used for billing purposes in ACT settings so the Anesthesiologist can get paid. The only anesthesia providers that need to be supervised are Anesthesia Assistants.

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