Charge nurse gave an antipsychotic without an order..how should i handle this?

[sallykk79]

I work at a skilled nursing facility as an LPN. We have a charge RN who has several years of experience. She is a very capable and knowledgeable RN. Let's call her "nurse X". To be blunt she is also very good at kissing a** to administration, and she is one their "good side."

Although she has good clinical skills, I have worked with her long enough to notice she isn't very ethical. We have a lot of dementia patients with frequent falls. This nurse frequently restrains patients (she will put a bedside table and position it in front of their wheelchairs so they cannot stand up or wheel themselves away). She will close the doors of known fall risk patients if they are being "too loud."

About 3 days ago we received a new admission with several broken bones from a s/p fall. He has not been able to get out of bed, and has been very restless, but manageable. He yells out intermittently, but since he cannot get out of bed all we can do is reposition him, provide verbal redirection, etc. which for the most part has been working.

I gave him a PRN pain medication early in my shift. About 2 hours later he fell asleep. He snored deeply and loudly throughout the entire shift. I thought it was odd that the pain pills I gave him would knock him out this much.

To make a long story a little shorter, one of the nurses working on the shift told me "Nurse X went in there and gave him something. She said it was something that was gonna take care of him yelling." I looked in his MAR thinking maybe she gave him something while I was on my lunch, but there was nothing showing he was given anything. He didn't even have any PRN's available besides the pain pills I already gave him.

At the end of the shift she asked me to co-sign medications that she disposed of (discontinued medications that needed to be destroyed). I noticed she disposed of a card of Seroquel. I found out that she took one of these pills and gave it to that patient WITHOUT A PHYSICIAN'S ORDER SO THAT HE WOULD "BE QUIET" DURING OUR SHIFT!! No wonder he was out cold! Looking back, I would bet my paycheck that she has done this to other patients too.

I am very upset about this. I want to report her, but I know she will deny it and I have no proof that she did this. I know she will find a way to deny that she gave this medication and she will know that I reported her. What would you do in this situation?

I appreciate any input :)

[mtmkjr, BSN]

I noticed she disposed of a card of Seroquel. I found out that she took one of these pills and gave it to that patient WITHOUT A PHYSICIAN'S ORDER

I think you forgot the part about how you found out she gave the Seroquel to your patient...

[Nascar nurse, ASN, RN]

I have no proof that she did this. I know she will find a way to deny that she gave this medication and she will know that I reported her. What would you do in this situation?

I appreciate any input :)

There's your answer in your own words. You have no proof that she did this. There's nothing further you can do

[sallykk79]

Highly unethical though, right? What if the patient had an allergy? She will likely do it again. Guess we will see.

[VivaLasViejas, ASN, RN]

Unfortunately, you are going to have to let this go. You have nothing but suspicion to go on, and that's not enough to make a formal complaint. That nurse probably *did* give your patient the Seroquel without an order, and if she did she deserves bad karma...but you didn't actually see her do it, so there's nothing you can do. Sad to say, she's going to have to be caught in the act, and my feeling is that she'll do it again and again until that happens.

With doctors and facilities trending away from giving elderly people hardcore antipsychotics, it surprises me a little that the AP was just lying around. Was it for another patient and had been D/C'd?

[JKL33]

1) I would not perform any wastes with this person unless I could verify the whole process and account for every piece of information that is being attested in a co-signor situation. I would try very hard not to put my name on anything that had anything to do with her.

2) In real time, *first and foremost*, I would have carefully assessed my patient and if he was not arousable or had significantly decreased LOC, I would have sent him to the ED.

3) I would have immediately addressed the information from the 2nd coworker by informing her that she must report it. I would tell her I'm sending my patient to the ED and she would be very wise to report what she knows.

You don't have the proof you need right now. Just the same, this is nothing to mess around with and you have to be prudent. You can't just sit around feeling all shocked that someone (allegedly) might do something like this.

I would look for a new job yesterday. That's just me. I wouldn't screw around with this situation in which the most likely thing would be that the patient's primary nurse would be blamed for what happens with a patient. You have zero defense against any accusations that could arise subsequent to another nurse causing your patient to become obtunded by medicating him/her with something off the record.

In the back of your mind you must be aware that Nurse #2 could've said something just to stir a pot. As you know, it's not at all uncommon for an elderly narcotic-naive patient to be zonked by a single pain pill or two. Just the same, this scenario is one too many wild-cards for my personal comfort.

[xanderx]

Sure is! I have encountered nurses like this, and there is nothing you can do. She will continue to shine and BS her way through her career.

[/username, BSN, RN]

You gotta be ******* kidding me. The nurse could have given him a warm blanket or fluffed their pillow, or any hundreds of things. To jump, without evidence or even something that could be construed as suspicion tells you that she gave that to your patient. You gave him oral pain medication, and after the pain medication was starting to take effect, he started to sleep.

What's more likely? That your patient's pain was resolved, and he went to bed, or that the charge nurse administered medication without an order to your patient, and then had you sign off on the waste?

[sallykk79]

Thanks everyone for your input. I spoke to the nurse about it and she did admit she gave him the AP without a doctor's order. Luckily he had no adverse reactions. Will take it from here.

[Hoosier_RN, MSN]

Never make an accusation without proof, but I would tell the 2nd nurse that you are going to management with her statement. And I would do so. Because if she's lying, this needs to stop. If she's not lying, then Nurse Xs actions need to stop. But watch your back, because if anything happens, you are liable regardless. If you go to management, express it as a concern that the 2nd nurse came to you with and since you're 'not sure' and only want the best for your patients, you feel this may need to be investigated

[SpankedInPittsburgh, DNP, RN]

I don't know if I understand. Did you sign for a waste you didn't see? If you did you verified that the pills in question were disposed of and not administered to patients

[Tenebrae, BSN, RN]

What was the pain relief you gave him?

It stands to reason that if his pain was adequately addressed he could have been able to sleep

As for finding out that she gave meds without an order, unless you directly witnessed it you have no proof and do you really want to drag a colleague through the mud based on something someone else may or may not have seen/heard/experienced

I once had a family member accuse me of medicating their mum to keep them quiet.

I gave PRN oxynorm for chest pain after it had been unrelieved by PRN paracetamol, PRN GTN spray, PRN mylanta (just incase it was epigastric pain) before I gave the PRN oxynorm

And as I respectfully said to the patient's family "your mum is not a noisy person, she was medicated because she had unresolved pain that had failed to respond to multiple other treatment options"