At what point do you send to the hospital?

RevYY · Jul 30, 2013

Hi Isis. I'm not an RN and yes I remember my schooling. Had you read my entire post you'd see that I stated at the facility I work at in Canada the charge nurse who is ALWAYS the RN makes the final decision. I did what was required of me I told the RN my thoughts and I was completely undermined to the point I called the director of care who told me it is what it is and the RN makes the final call based off my information and assessments. I fulfilled my duties and documented everything including my opinion that the resident should have been transferred to the hospital or at least have the MD notified. I realize that policies are different in the states I was just looking for some general advice and not a lecture about how I was neglectful. I thank you for your opinion and I was not happy about the decisions made, hence why I was asking for advice. Unfortunately, I did all I could do and to answer your question I would be livid if it happened to my family member. I've only been at the facility for not even a month and I have to say I disagree with their policies and procedures and will be looking for employment elsewhere. I will also make sure to ask what their policy is in situations like this. Lesson learned.

If that is your policy, that is your policy. So after you informed the charge, you would chart a note that you determined a change in the patient, and reported it to the charge nurse, per policy.

BrandonLPN, LPN · Jul 30, 2013

I don't know about Canada, but here a practical nurse certainly can call the physician and take telephone orders. Including the order to send to the ER.

But if there's a RN on duty and policy says she's the one who's to notify the doctor and all that, well, policy is policy. I would document my assessment and then very clearly document that "Mary Sue, RN supervisor, was notified of change in condition." Anything that happens after that is on her head. If she failed to go assess this resident herself after what you reported, then she isn't a good nurse.

With that said, if truly nothing was being done by the RN and the resident was circling the drain, I'd just go over her head and call the doctor myself. Screw policy.

Also, I hope yo didn't really write in the chart that it was "your opinion" that not enough was being done. Never, ever write something like that in the nurses notes. Never. That's worse then writing "incident report filled out".

chrisrn24 · Jul 30, 2013

I don't know about Canada, but here a practical nurse certainly can call the physician and take telephone orders. Including the order to send to the ER.
But if there's a RN on duty and policy says she's the one who's to notify the doctor and all that, well, policy is policy. I would document my assessment and then very clearly document that "Mary Sue, RN supervisor, was notified of change in condition." Anything that happens after that is on her head. If she failed to go assess this resident herself after what you reported, then she isn't a good nurse.
With that said, if truly nothing was being done by the RN and the resident was circling the drain, I'd just go over her head and call the doctor myself. Screw policy.
Also, I hope yo didn't really write in the chart that it was "your opinion" that not enough was being done. Never, ever write something like that in the nurses notes. Never. That's worse then writing "incident report filled out".

Yes! Haha

Esme12, ASN, BSN, RN · Jul 30, 2013

I think that we, as members, have to remember that allnurses although based in the USA.......it is an international site and that it hosts nurses/members from all over the world. Just as policies and procedures change from facility to facility and state to state....I am positive the policies vary greatly country to country......so we need to keep this in mind when we respond.

OP....I would ask to have a sit down with your manager/director/boss/chief nursing officer....someone in charge and ask what you should do in a situation like this when it comes up again (and it will) like IrishErin shared.....

I had been in a similar situation at an LTC home in Canada as well, I called the family and asked for their wishes. Mind you, the pt was not a dnr. The RN had been unconcerned but I couldn't ignore the symptoms. Turns put the pt had indeed suffered from an ischemic stroke. I did receive a "talking to" for going over the RN's head but ultimately I did the right thing. I didn't stay long there and am happy in my current place of employment.

calling the MD and circumventing the RN in charge is the right thing to do....but it might have you lose your job for circumventing the policies.

Bless you for caring. Sometimes doing the right thing isn't easy.

canadianhungarian · Jul 30, 2013

You did the right thing by wanting to send them out. You put patient safety first. Sadly the RN did not. I have never worked LTC yet! ( saying yet because you never know) but I do get a few shifts on rehab floors. Similar in a sense that some rehab hospitals here in Canada you do have to send them further on to ER should there be a significant/untreatable change in conditions. That would still warrant a visit to the hospital in my opinion. As a previous poster said its your liscense on the line ----and you have valid points for wanting to advocate. Patient safety is always first.

sallyrnrrt, ADN, RN · Jul 30, 2013

I think that we, as members, have to remember that allnurses although based in the USA.......it is an international site and that it hosts nurses/members from all over the world. Just as policies and procedures change from facility to facility and state to state....I am positive the policies vary greatly country to country......so we need to keep this in mind when we respond.
OP....I would ask to have a sit down with your manager/director/boss/chief nursing officer....someone in charge and ask what you should do in a situation like this when it comes up again (and it will) like IrishErin shared.....calling the MD and circumventing the RN in charge is the right thing to do....but it might have you lose your job for circumventing the policies.
Bless you for caring. Sometimes doing the right thing isn't easy.

well said esme12

jamd11 · Jul 30, 2013

I don't know about Canada, but here a practical nurse certainly can call the physician and take telephone orders. Including the order to send to the ER.
But if there's a RN on duty and policy says she's the one who's to notify the doctor and all that, well, policy is policy. I would document my assessment and then very clearly document that "Mary Sue, RN supervisor, was notified of change in condition." Anything that happens after that is on her head. If she failed to go assess this resident herself after what you reported, then she isn't a good nurse.
With that said, if truly nothing was being done by the RN and the resident was circling the drain, I'd just go over her head and call the doctor myself. Screw policy.
Also, I hope yo didn't really write in the chart that it was "your opinion" that not enough was being done. Never, ever write something like that in the nurses notes. Never. That's worse then writing "incident report filled out".

I charted what was expected of me. I'm not sure how it is in the USA, but we chart everything that happened including dialogue had with anyone present. So I charted in the progress note the dialogue that I had with the charge nurse and the DOC. I probably didn't write in my "opinion" I don't have it directly in front of me but in there is my documentation of the dialogue with all parties. If you don't chart it , it didn't happen. As a previous poster stated, nursing in different countries varies... expectations, responsibilities, schooling, the dreaded policy, and so on. Now I know I could have done things differently, that I am sure of, it was an exceptional learning of what NOT to do next time. I will never let a policy get in the way again- that is if I feel it is threatening to the patient safety. I'm also in no way trying to be ungrateful, spiteful or rude because of the previous comments that I was neglectful or being irresponsible. I am happy people are taking the time to read my situation and give their input.

As for this post I thank everyone for posting. I will take everything that has been said into consideration as I am still learning the ropes. BUT, its gone way too off topic. I wasn't directly looking for advice of what I did wrong and could have done better. I've already reflected and spoken to everyone, including my union an DOC that I needed to about this situation regarding policy and my responsibilities.

I was originally asking for an experienced nurses opinion of when you would send a LTC, DNR patient to the hospital, what is severe? Maybe to specify from what I explained about the patients change in status, did I miss something that would lead the charge RN to not think the client's health status change wasnt' warranted enough to call the MD or send out to ER? I know too many people who say "who cares, they are DNR" or "why bother they are living in hell as it is let them go" , etc., etc. I hate this way of thinking

jamd11 · Jul 30, 2013

I also would like to post that I cannot work for an institution that does not value my opinion and have since given my notice and gained employment elsewhere. You can be sure to know I asked what the polices are regarding this situation :).

In speaking to the DOC and my union rep, I asked why such a policy was ever implemented in the first place. The response was that 'too many people were abusing it to ship away residents with bad behaviours'. I guess whenever a severely demented patient was causing problems and their scheduled doses and prns were not cutting it, the nurses would ship them off to the hospital because they did not want to deal with them, claiming they were a danger and aggressive. They would receive a shot of something strong, a new order for something stronger and be sent back completely snowed. She said that allowing the RN to make the final decision was a way to minimize this, or something rather.

This is just what the DOC told me was the reasoning behind implementing this policy. I understand the frustration but I complete disagree with it.

Pepper The Cat, BSN, RN · Jul 30, 2013

Canadian RN here.

Yes, the pt should have been sent out, I think.

However, that being said, I doubt it would have effected the long term results. Sounds like she had a stroke, and the damage had been done. Even if the stroke was caused by a clot, I doubt she would have met the required time window for TPA.

The doctor should definitely be informed of the change in her health status! How has her BP been since? Has her swallowing status been reassessed? She may need a change in diet too. I am concerned about the care this pt is receiving!

jamd11 · Jul 30, 2013

Thanks for your comment!

Her BP and temps have been fluctuating between baseline and outrageous. Now this happened about two weeks ago and I just posted yesterday or the day before I forget :S haha. I did say she was now a hoyer lift, but she is actually dragging herself around in a wheelchair now with her right foot, mind you before she could walk. I havn't been on that unit since it happened so I'm not 100% about the swallowing assessment but when speaking to my coworker she doesn't eat much at all, just plays with her food and doesn't know what to do with it. I think dietary changed her from whole food to minced.

I also inquired this am if the doctor has even been in to see her and I did find out the day charge nurse that I gave report too called the doctor, but they came to see her like a day or two after and basically told the girls to just monitor her.

KimO peds · Jul 30, 2013

That is so unfair to the patient! She obviously had a severe stroke and NO MEDICAL ATTENTION. LTC or not, she still has a right to care medical help. It sounds like you did what you could/should have with the policy you have in place, but your RN should seriously be fired over this.

jamd11 · Jul 30, 2013

That is so unfair to the patient! She obviously had a severe stroke and NO MEDICAL ATTENTION. LTC or not, she still has a right to care medical help. It sounds like you did what you could/should have with the policy you have in place, but your RN should seriously be fired over this.

I know I am so appalled over this. There are a select few RNs that are not in it for the care and enjoyment of helping others at this facility. For the most part they are amazing. But its like ripping finger nails off for about 3 of them to get them to send anyone to the hospital.....one told me when I stated he didn't like the paper work and documentation and readmission requirements if they were admitted or gone for 24 hours. So he avoids it at all costs. I dont get it