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.
I can't contribute anything useful here. I just want to say it p*sses me off that RNs are put in such a crappy situation that pressures them into unsafe workarounds. And then to top it all off, there is little if any thought or energy put into improving the system. It seems to be a blame game.
And really? An RN is expected to notify the physician to give permission to hold a medication that has no legitimate reason to be held? Other than the said medication isn't physically present to be given? What is the purpose of that? What's the physician going to do? Ride in on his/her stallion with said "Lifesaving Carafate?" I'd be irritated, too, to be on the receiving end of a bogus call like that. But again, the RN is stuck in that unhappy position to either document the scenario accurately (and face discipline) or make a stupid pointless phone call (and face anger and disrespect from the physician). And either way, there is no benefit for the patient. So why should these be the two options? Something is really, really wrong here.
What if its Coumadin??? And we just got back PT/INR results that require a change in dosage but the current dose is too much. Coumadin has to be given.
Thank you everyone for your thoughts and encouragement. Looking back, it seems like a no brainer but at the time I thought I did the right thing to move on and keep on with the med pass for the rest of the residents (LTC and Skilled side). I am still slow with that and didn't want to be late, resulting in more med errors.
I still think I did the right thing, other than not notifying the MD. Lesson learned. What other lessons am I going to have to learn not due to bad nursing judgment, but due to LTC nuances and "rules" that I know nothing about?
If the economy weren't so bad, my family and I weren't so desperate, I would probably have left this facility for other reasons and I still might. I am taking it shift by shift. Lots of us new grads are in this situation and are trying to make the best of it.
.....And really? An RN is expected to notify the physician to give permission to hold a medication that has no legitimate reason to be held? Other than the said medication isn't physically present to be given? What is the purpose of that? What's the physician going to do? Ride in on his/her stallion with said "Lifesaving Carafate?" ......
Oh and this really gave me a much needed laugh. Thank you!
What if its Coumadin??? And we just got back PT/INR results that require a change in dosage but the current dose is too much. Coumadin has to be given.
I am unsure of what you are saying.
Are you saying if you recieved a high INR you would still administer a dose of coumadin?
I would hope you would have standing orders for a sliding scale. Usually we are given a range, if in the range continue, if out of range by x-xx amount increase or decrease dose by x amount, if outside given range, ie critical range repeat INR with iSTAT, hold dose, and contact practitioner.
Again we keep an E-kit managed by pharm with various doses of coumadin to allow various dosing changes.
Thank you everyone for your thoughts and encouragement. Looking back, it seems like a no brainer but at the time I thought I did the right thing to move on and keep on with the med pass for the rest of the residents (LTC and Skilled side). I am still slow with that and didn't want to be late, resulting in more med errors.
I still think I did the right thing, other than not notifying the MD. Lesson learned. What other lessons am I going to have to learn not due to bad nursing judgment, but due to LTC nuances and "rules" that I know nothing about?
If the economy weren't so bad, my family and I weren't so desperate, I would probably have left this facility for other reasons and I still might. I am taking it shift by shift. Lots of us new grads are in this situation and are trying to make the best of it.
You did do the right thing, good for you.
Just for future reference find out what your practitioner wants as far as non emergent contact in off hours and find out what the OOS med administration policy is for the facility. Many times the pharmacy will actually have a medication manual that will have a prescribed policy fror OOS meds.
Always do the right thing, always...even if it means self reporting med errors.
LOL no one is going to say what is the wrong/right thing they would have done which is to ask once and not make a big deal. When it was obv there was nothing to be done as far as getting it then give other 2300 meds and wait an hour to see if pt noticed and chart as given. Then make not to fax pharm for next admin. If coworker asks tell them you had overlooked it. Obv this place has no pyxis by how country it sounds. I have worked at places like this before and they will def contribute to you facing state board. I had manager call me when I was working agency and ask if I gave all the dilantins because there were extra. smh. 'look at the charting' I said. Then another nurse lied about giving something and she called me to ask about a conversation we had. I was like 'if it aint documented it aint done and vice versa' so 'I dont remember look at the charting' all the while making a mental note not to answer the phone for them again after I clock out. And I didnt! Only thing is when OTHER NURSES (lol) do things like falsely documenting they have to always check and double check and cover their own a$$ which is why it is not advisable.
From a legal standpoint I wouldnt give a jack sh*! about charting it wasnt there if it wasnt. And if the hospital wanted to make something of it I would call every state organization I could, but that confidence comes from experience and they are basically playing on your inexperience. Trust me, you will be the fall person if the fit ever hits the shan. Trust that. But reporting them you have to be prepared to pack your stuff, but then there is whistleblower protection. Its a tough titty kid but you gotta make up your mind. Thats how nurses get caught in pickles, damned if you do, damned if you dont. But what everyone else has said is illegal too, not charting the truth. As another said you could always 'borrow back' I didnt know borrowing and replacing later was illegal. As long as you follow the 5 rights of administration.... I feel for you, good luck.
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.
I have to agree. I got so tired of coming in on the night shift and being short on certain meds because no one bothered to re-order. Takes two seconds. Our pharmacy at our old job left at 4:30pm and the supervisors stopped having access to a cabinet with extra meds. Being a little proactive for the next shift is just common courtesy.
so what was she supposed to do, chart wise, if the med wasnt there?
i agree a call to the md to say the dose wasnt given... maybe he could have given an order to d/c that one dose? i dunno.... what was she supposed to do, besides call the md? (thats the only infraction i saw)
Are you saying if you recieved a high INR you would still administer a dose of coumadin?
I would hope you would have standing orders for a sliding scale. Usually we are given a range, if in the range continue, if out of range by x-xx amount increase or decrease dose by x amount, if outside given range, ie critical range repeat INR with iSTAT, hold dose, and contact practitioner.
Again we keep an E-kit managed by pharm with various doses of coumadin to allow various dosing changes.
No I am saying if the MD has them on 4mg for example. But the dose is reduced to 3.5mg or 3.. or increased to 4.5
We need to borrow. Because you can't futz around and get orders to hold coumadin because you don't have the pack in for that patient from pharmacy.
No I am saying if the MD has them on 4mg for example. But the dose is reduced to 3.5mg or 3.. or increased to 4.5
We need to borrow. Because you can't futz around and get orders to hold coumadin because you don't have the pack in for that patient from pharmacy.
.
You don't have an E-kit with multiple mg doses of coumadin?
If the dose is critical high we hold and start next day. If there is only a dose change we continue with the old dose until the new doses arrive or unless we have it in the E-kit. 99% of the time we give with the E-kit.
The MD is notified of our inhouse abilities when they give the order of course so the orders reflect that.
You don't have an E-kit with multiple mg doses of coumadin?
If the dose is critical high we hold and start next day. If there is only a dose change we continue with the old dose until the new doses arrive or unless we have it in the E-kit. 99% of the time we give with the E-kit.
The MD is notified of our inhouse abilities when they give the order of course so the orders reflect that.
SaltyNurse
82 Posts
I can't contribute anything useful here. I just want to say it p*sses me off that RNs are put in such a crappy situation that pressures them into unsafe workarounds. And then to top it all off, there is little if any thought or energy put into improving the system. It seems to be a blame game.
And really? An RN is expected to notify the physician to give permission to hold a medication that has no legitimate reason to be held? Other than the said medication isn't physically present to be given? What is the purpose of that? What's the physician going to do? Ride in on his/her stallion with said "Lifesaving Carafate?" I'd be irritated, too, to be on the receiving end of a bogus call like that. But again, the RN is stuck in that unhappy position to either document the scenario accurately (and face discipline) or make a stupid pointless phone call (and face anger and disrespect from the physician). And either way, there is no benefit for the patient. So why should these be the two options? Something is really, really wrong here.