Common LTC no-no's (part vent, part question)

[Zergasaurus]

I have a typical story, new grad working in LTC after a short orientation. Shift is 10p to 6:30a (reality is more like 9:00p to 8:00a), alone with two aides - some good, some not so much. Of the four aides I have worked with, the two I was told were "great" scare me the most.

My anxiety level is tremendous. It seems like I am finding out in a roundabout way of what to do or even more importantly what NOT to do. Example. Second shift on my own after orientation, pt had 2300 Carafate. No carafate to be found anywhere. Swing nurse who was there late charting first told me "get one from another pts card". That felt wrong (and no other pt was getting it anyway), so I asked what my other options were and she said to call the pharmacy. I did, they said it would be delivered next day. Gave the other 2300 meds to the pt, who laughed and said this has happened before and no big deal. I went back to ask the swing nurse what else to do and she had left.

I later circled it on the MAR and noted, "med not available, pharm called pt aware no adverse effects noted"

Now a week later I get written up and was told that you NEVER say a med is unavailable (even though it WAS unavailable!!!) and I did not call or fax the MD. I now understand I should have notified the MD about the carafate and I take responsibility for that but I am wondering what else I am missing or doing wrong trying to muddle through this by myself? Information at this facility is conflicting at best and I am not entirely sure what to ask.

Question. What are common LTC rules and procedures that I should know about and be following? I need this job for the moment for experience and paycheck that my family needs and just want to make it without getting into more trouble and it possibly being worse than this carafate thing.

Thank you.

[SuesquatchRN, BSN, RN]

Charting that something is unavailable, even if he were admitted at 4 pm and pharmacy had made their last run, will get the facility cited. Don't document that. And borrow. There's nursing school, then there's reality and legality. And State waiting to swoop. Not that I am SAYING I would ever borrow, because State'll getcha on that, too. Got it?

You should not, however, have been written up for doing the right thing. Which you now know is not the right thing. GAH!

Hang in there.

:)

[KtHospiceRNCM]

I'm still a student, but we were just told last week to never write anything negative, such as med not available, on the MAR or in the pt charting. we were told that is throwing our co-workers under the bus so to speak and that when there is an issue as a result of other staff/faculty we should write it up on whatever our facility provides such as an abnormal occurrence or something like that.

documentation takes awhile to get down and will start to flow after awhile. one of those things that come with time we were told.

good luck to you!

[Asystole RN]

Sorry to hear about that, it's a catch 22.

It's against Federal and State law to "borrow meds" (misappropriation of patient assets, insur fraud etc.) BUT if you write "not available" you get your butt chewed to pieces. Personally I would not make it a habit of borrowing, some meds are very EXPENSIVE and belong to that individual patient. It is a personal ethical question, some see it ok to steal as long as the dollar amount is small...others think it is wrong to steal period. The person who allowed the card to go empty should have been disciplined.

Now on notifying the MD...

I would have made a note for the MD to be notified in the AM or a note placed in his folder, left voice message, or text message depending upon the preferred route of non urgent contact for that practitioner. For Eve shifts after business hours or night shift I never contact the MD unless I need urgent orders or unless it is an emergency.

You must notify the MD that is a given, most MDs do not want to be bothered with non emergent calls on off hours and most have made available a secondary non emergent means of communication.

On being written up...

#1 Always make a copy, #2 never sign it, and #3 make them cite in the write up your exact infraction and where it is listed in the employee handbook.

It makes some managers angry but you do this and you will most likely be left alone in the future. Managers are less likely to discipline you when they are held accountable for their words. Copies of inappropriate write-ups have a tendency to make their way to the BON or Dept of Health...

[SuesquatchRN, BSN, RN]

You can borrow "back," asystole.

[Asystole RN]

You can borrow "back," asystole.

Stealing is stealing. Robbing Peter to pay Paul is a very poor policy. Not only is it ILLEGAL, but is also immoral IMHO. To each his own though.

What is a better policy is going through the cards and simply reordering the meds when they are within the 3 day empty window...takes all of 5 seconds.

My pharmacies all have cards with reorder stickers, pull those off and throw them on a piece of paper and fax away. We also assign certain shifts to maintain the med counts so that we do not run out.

Surprises surprise meds arrive on time with no need to steal.

[Asystole RN]

I'm still a student, but we were just told last week to never write anything negative, such as med not available, on the MAR or in the pt charting. we were told that is throwing our co-workers under the bus so to speak and that when there is an issue as a result of other staff/faculty we should write it up on whatever our facility provides such as an abnormal occurrence or something like that.

documentation takes awhile to get down and will start to flow after awhile. one of those things that come with time we were told.

good luck to you!

The person throwing their coworkers under the bus is the nurse(s) who saw the card with a sub 3 day supply and did not bother to reorder the med nor follow up.

It would be like blaming the police officer for the traffic when all he is trying to do is clean up the accident...blame the person who was negligent, not the person doing the right thing.

[Zookeeper3]

sesquatch, if you review the Joint commission mandates... every facility if moving into a NON borrowing policy. As it is creating med errors. The student... go figure and good for you... is correct. Borrowing is now against joint standards.

This borrowing in addition is a medicaid/medicare fraud and is a reportable ofence as one patient has been charged for the med and it is now being "stolen" to give to another that has not paid for it. Our corporate compliance policy prohibits it because of the fraud potential with billing.

What is a norm to some, may not be a main stream standard. OP, just go to the joint commission site for proof and refuse to sign the write up and ask to review the policy of how to obtain a med in after hours. Sending someone to a pharmacy may very well be part of it.. crazier things have happened. Also review the charting policy, there are loopholes to both protect you and your facility and please speak to your peers in report for suggestions.

[SuesquatchRN, BSN, RN]

JCAHO does not govern LTC. Your state's DOH does.

Every facility bars borrowing. On paper.

I thank everyone for the lectures on morality. I was not talking about how it should be in a perfect world - meds always ordered in a timely fashion, no late admits needing metoprolol when Pharmacy is 60 miles way and closed - but about reality.

But hey, I am sure the next time the OP is out of carafate her fighting with the DON and citing policy and law will help her keep her job.

[Bella'sMyBaby]

If a medication is NOT available, it's NOT available & that's exactly what I would document in the MAR. The facility is NOT going to back you if you get reported to Licensing Board. Don't make the facility's problem YOUR problem.

[Asystole RN]

JCAHO does not govern LTC. Your state's DOH does.

Every facility bars borrowing. On paper.

I thank everyone for the lectures on morality. I was not talking about how it should be in a perfect world - meds always ordered in a timely fashion, no late admits needing metoprolol when Pharmacy is 60 miles way and closed - but about reality.

But hey, I am sure the next time the OP is out of carafate her fighting with the DON and citing policy and law will help her keep her job.

You cited valid real world problems.

Have you ever thought to work with your facilities policies, the pharmacy, and the DOH to resolve the problem?

We were having issues like you stated until we worked a deal with several pharmacies. One pharmacy would STAT out a single days worth of meds (arrives within 4 hours) without question unless the cost is greater than $50, then needs case manager approval. Usually that first days meds will get us through until the primary and/or secondary pharmacy sends the meds the next day.

Edit: OR we have the MD write an order to start meds "when available from pharmacy" which is actually a very common order esp with odd/rare/expensive IV meds.

Even with this we were having problems with getting the meds on time so instead of having 1 E-Kit med box we ordered several, one per station PLUS invested in a Pixis system.

If she were to be fired for obeying Federal and State law plus the DOH then wow, her lucky day since she would never have to work ever again after that lawsuit. Hence the get a copy of the write up...

There are ways to work around and plan for emergencies...just have to make the effort.

[SuesquatchRN, BSN, RN]

Of course I have thought of working with TPTB. Think rural, think *a* pharmacy, think a controlling DON, and there is certainly not going to be a perfect Pyxis in most LTCs. And she could not be censured for the grave crime of borrowing since there would be no paper trail or anything else to prove it.

This is her first job. Do you really think that advising her to lead a rebellion against TPTB is going to help her keep it? She WOULD be fired in a heartbeat for deciding that she is crucial to shaping the facility's methods over and above the, you know, DON. That wouldn't get her in trouble. Nah. Her shiny new nurse-ness would be really well-received when she tried to force the facility to conform to what should be. Uh huh.