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

Specialties Geriatric

Published

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. :confused:

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.:crying2:

Specializes in Professional Development Specialist.

By all means, call and notify the doctor and get a TO at 2300 to hold the carafate until available. That is the correct procedure in my facility. See how that goes and how many more times you have to do that and get an earful before you borrow. It would be nice to work in a perfect world. Our pharmacy would say the same thing, it will be delivered on our next run at 11am the next day.

In a perfect world all previous nurses would have prevented meds being out and reordered in a timely manner. But when you have 30+ patients and 100 other responsibilities sometimes reordering a med gets missed.

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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.

Since you have thought of it why have you not? Talk to the DON and the pharmacy in a honest, straightforward, and professional manner.

Setting aside possibility that the OP may work 32,000 miles from the nearest pharmacy, have Lucifer as a DON and be held at gun point by Al Qaeda I am sure she has options. You have very unique issues, I am sure there are options for you too if you were to pursue them.

No one said lead a rebellion, just investigate options. No Professional Registered Nurse should ever allow themselves to be steamrolled by leadership. She should know her rights, know her handbook, and use those rights and handbook. If you cannot stand up for your own rights then you cannot stand up for your patient's.

I am sorry you have had such a hard time SuesquatchRN, I am sorry for you. Sounds like you are a veteran of many political battles but advising someone to lie, steal and cheat is just...ridiculous. She may have more than 1 pharmacy, she may have facility policies in place that she is unaware of, she may have an awesome DON but no one will know until she starts to investigate and work with the facility.

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By all means, call and notify the doctor and get a TO at 2300 to hold the carafate until available. That is the correct procedure in my facility. See how that goes and how many more times you have to do that and get an earful before you borrow. It would be nice to work in a perfect world. Our pharmacy would say the same thing, it will be delivered on our next run at 11am the next day.

In a perfect world all previous nurses would have prevented meds being out and reordered in a timely manner. But when you have 30+ patients and 100 other responsibilities sometimes reordering a med gets missed.

Very true, but that is why you have a secondary and tertiary back up plan. (E-Kit, Pyxis, STAT pharm delivery)

That is also why those who allowed the cards to go empty should be punished.

That is also why you should establish rapport and a protocol with your practitioner on how, why, and when they wish to be notified.

There are real world solutions for real world problems.

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You are making a lot of assumptions about what I have and have not done, asystole, as well as presenting them in a condescending, supercilious manner. I am glad your world is so black and white, with no shades of grey. Most of us live down on the ground, not in ivory towers. I am simply advising someone that tilting at windmills will be no more effective for her than it was for Don Quixote.

I admire your zeal. I cannot in good conscience advise the OP to enter into a battle that she will, undoubtedly, lose.

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you are making a lot of assumptions about what i have and have not done, asystole, as well as presenting them in a condescending, supercilious manner. i am glad your world is so black and white, with no shades of grey. most of us live down on the ground, not in ivory towers. i am simply advising someone that tilting at windmills will be no more effective for her than it was for don quixote.

i admire your zeal. i cannot in good conscience (interesting choice of words considering we are debating if the op should lie and steal for professional conveinence...) advise the op to enter into a battle that she will, undoubtedly, lose.

i apologize if i sounded condescending or if i offended you, that was not my intention.

i do not advocate a "battle" or some other aggressive, professionally suicidal tactic.

i just simply think she should explore some of the ideas i have presented, of course in a professional, well prepared, open manner. lying, stealing, and committing felonies should not be something a professional registered nurse should advocate...ever.

what is professionally convenient and what is ethically right are not always the same thing, but that is what separates professional registered nurses from the rest...we are supposed to put on our big boy/girl pants and face the ethical challenges that are presented to use and make the right decision.

this is the unfortunate reason why we have to have such regulating entities as a bon, doh, jcaho etc...not everyones moral fabric is of the same quality.

p.s. being called "black and white" and in an "ivory tower" are firsts for me...never thought advocating against a class 6 felony was such a hoity-toity thing. :rolleyes:

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We have some unique issues regarding meds too. We are a very small facility, with a small pharmacy. I have called them when I was out of something and was told to borrow from another resident...by their head pharm! We were on automatic refills, but that left us in a bigger mess...soo many of one med and none of the others. The issue that comes up with borrowing (yes, I have borrowed before) is that person you have borrowed from is now going to run out BEFORE they are due for a refill. I seen someone borrow Cymbalta from another lady for days. When I called for a refill for the lady...they said "sorry, she should have enough for another 5 days!" First, I was so angry that someone was out for that many days and never bothered to notify the pharmacy and second, that they borrowed for 5 days leaving the lady short!

Also, My Director would flip if we ever wrote N/A

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Specializes in LTC.
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. ;)

Our pharmacy has the same thing. But sometimes the sticker walks off the blister pack and doesn't get reordered so I have to write it on the reorder form.

But aside from that. If we can't write "med not available call out to pharmacy"(which I have done but it was for like a cholesterol med) or borrow.. but we have to give that med?

What are we supposed to do? Sit in the corner and rock back and forth and babble on because the med wasn't here?

I borrow. Peter needs his meds and Paul needs his meds too.

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Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

Technically and legally, it should have been that you called the MD, got an order to hold the med until it was available and documented this. The nurses who did not reorder the medications should also have received discipline. I have not seen a citation written when the nurse has done the "hold" until available procedure. I mean, I wouldn't hold you at fault, however, in my position, I would be discussing the re-ordering policy with administration. You know, borrowing is illegal. There is a regulation in the pharmacy and federal regulations regarding this practice. However, although I don't condone it, I know we all, at some time, have done what we had to do. There is what we call "real life" situations. As a nurse we all know that things don't always go like the "book". We wish they would, and indeed it would be a perfect world.

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Our pharmacy has the same thing. But sometimes the sticker walks off the blister pack and doesn't get reordered so I have to write it on the reorder form.

But aside from that. If we can't write "med not available call out to pharmacy"(which I have done but it was for like a cholesterol med) or borrow.. but we have to give that med?

What are we supposed to do? Sit in the corner and rock back and forth and babble on because the med wasn't here?

I borrow. Peter needs his meds and Paul needs his meds too.

What you are supposed to be is #1 be proactive, #2 have back up plans, #3 get the practitioner involved if necessary.

I understand the "He NEEDS the meds statement." Hear it all the time.

Now on a personally not I deal in infusion so my examples will be focused there. If we have a pt who is known to react to a certain med or may have a reaction requiring diphenhydramine push the IV nurses make sure that we have enough on hand to medicate that pt, his family, and the greater City of Phoenix. If we have a brittle DM2 and need to have D50 amps on hand we make sure we have several. The excuse of "not on hand" is NOT accecptable.

If the pt needs the med then we need to keep on top of ordering them. And yes we have had to send a nurse to Walgreens, sometimes Walmart on occassion...

Like stated before my facility not only maintains the patient's meds with a 3 day buffer, typically day shift is responsible for ordering, night shift to follow up but also we have multiple E-kits, and a Pyxis plus a secondary STAT pharmacy on contract. The multiple E-kits and pyxis are expensive, and many smaller facilities may no be able to accomodate but the 3 day buffer and shift ordering are not a big deal and are easily implemented.

If all that is not possible then contact the practitioner and get a hold order or if you have a standing order, many of my patients do, then use them

We have standing orders for falls, inability to administer certain meds, etc. No big deal since we are covered with orders.

What do you do if someone runs out of Depakote or a narcotic?

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Asystole, you do not work in LTC.

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Asystole, you do not work in LTC.

Actually I do. ;)

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Specializes in LTC.

Then why don't you get what we are saying.

The med is not always reordered and to write someone up because they didn't reorder a med is ridiculous.

I am not waiting around for pharmacy or doctors orders to hold the med. I find another who is on it.. . pop it in the cup.. give the med.. and move on. I add the med to the list of things that need to be reordered which I fax to pharmacy at the end of the shift.

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