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.
this has been the most common problem in the several ltc facilites where i have worked. some of the ltc facilities were privately owned, others owned by various corporations. that being said, the privately owned facilities utilized the "mom and pop" pharmacies that were pleasant to work with, and very willing to "make the system work." these pharmacies depended on the contracts they had with the privately owned ltc facilities (as well as business with their individual customers) for their survival. pharmacies that are owned by corporations have contracts with a number of ltc facilities. these pharmacies have many employees, and are not customer service oriented, imo. each time i have made a call to said pharmacy, i speak to a different pharmacy tech, and have to repeatedly ask: "why do i not have the medication, when it was ordered two days ago?" frustrating is an understatement. my co-workers and i have repeatedly made tptb aware of this never ending issue. despite the don addressing this issue with a pharmacy representative (assigned to the facility) on a regular basis, the issue(s) continue.
start asking for the pharmacist himself...you get much better results going to the horses mouth. we had so many issues with "faxes missing" we actually recieved the pharmacists private fax number after talking to him about the issue. since then the issue has magically resolved.
it never occurred to me to contact the corporate compliance officer with regard to this issue; what a great .
instead of , this may be a step in the right direction.
the problem with most of the ltc facilities i have known is that no one bothers to say anything, if they do it is usually in the form of yelling lol.
"asystole," thank you for your comment regarding the order to have the physician state: "begin the medications when available from the pharmacy." this order is an easy solution to circumvent a state citation for writing "na." however, if a newly admitted resident has not received a medication that is considered critical for a fragile cardiac problem (for example), this becomes a dilemma. do i "borrow" the medication, or just wait for the pharmacy to "make their run?" what do i do if no other resident takes a certain medication (such as pacerone, for example)? requesting the pharmacy to deliver a medication "stat" equates to a wait time of up to four hours for the medication to be delivered! a back up e box is not workable for this type of issue; this would require a back up med cart to store the numerous, specific medications prescribed for residents. routine meds (colace, mvi, etc..) are stock, and would not be included on the back-up cart. many of the medications have short expiration dates; no corporation would view a back up med cart as "financially sound." what is optimum for residents is secondary, despite the corporation stating "residents are our priority." unless you have been living under a rock, we all know this is a bunch of "bunk." whose responsibility would it be to routinely check the back up med cart? in all probability, it would be assigned to an already overburdened nurse; "just" another task that takes away time to actually care for the residents. quality of nursing care spirals downward once again.
the e-kit is actually just stored in a large fishing tackle box in the med room with many of the more common meds. the box is often rotated out, actually everytime the box is opened we fax a use form to the pharmacy and they dispatch an entirely new box out. they get changed out nearly on a daily basis. the meds never have a chance to go old. we have a pretty good rapport with the pharmacy so if we need any special or odd meds in the e-kit they'll drop it in there for us...we just have to make sure to ask ahead of time.
when the floor nurse recieves report from the hospital we already have the chart in hand and all the final adjustments are made, hospital only meds dc'd etc and they are faxed to pharmacy. we usually recieve report 2-6 hrs before pt arrival, the patients rarely sit long without their meds. if the med is rare or takes a long time to recieve for whatever reason then the md is notified and orders written accordingly.
to all nurses who work in facilities that have solved this conundrum, you and the residents/patients/clients are fortunate.
suesquatch," thanks. "zergasaurus," you are an astute new grad.
enough said. thanks to all for giving me the opportunity to post my lengthy .
scoochy
not all the meds can be kept in an e-kit for the issues you described but 98% of the meds we give in ltc can...
This brings me back to a huge pet peeve. I work days. Many admits come in on second shift. The second shift supervisor is tasked with writing out the orders and faxing to pharmacy. It seems that between smoke breaks, ordering dinner, and dealing with the patients they just don't get around to writing and faxing those orders til the middle of the night...and frequently I'll see where they weren't faxed until 6am for a pt. that arrived at 5pm the previous evening! Then there are the times they were never faxed at all...
Well, now I have to give this pt. their 47 meds and I have nothing...N-O-T-H-I-N-G to give them. The ebox has antibiotics and a couple cardiac meds in it on a good day. Some med passes I have three or four new pts in need of critical meds like decadron, psych meds they aren't supposed to miss doses of, cardiac meds, etc. Frequently we get dialysis pts. and we wont have anyone in the house on their meds to borrow from even if we were contemplating the ultimate sin of "borrowing" meds. It is so frustrating. I have brought it up to several people in the chain of command who shake their heads and agree with me but don't say anything to the supervisors in the habit of doing this.
Huh. Our evening nurses work so short that I am impressed they even survive the shift. Seriously. Each hall has one nurse and a supe for the building. 120 beds.
Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.
"Asystole:"
We order all medications electronically. Yes, I have spoken with pharmacists, but to no avail, it doesn't help. The pharmacy is owned by a corporation; we are just one of hundreds of customers.
Lucky! Our night shift is one LPN, two CNAs for 40 residents and 8 assisted living residents. If we are in dire need, we can call the pharmacist at home and he will call the hospital and tell them to give us the much needed med. We have a 6 bed rural hospital attached but not part of our facility.
Assytole..I'd be interested in knowing what pharmacy your facility uses and what type of LTC you work in?
Have any of you had a chance to read the thread on Omnicare? You will see a a lot of these issues noted there.
Many of the "chain" LTCs are unable to choose the pharmacy and end up with the big box. No switching or picking and choosing.
Yes, if you have a problem they have people to call BUT not at night and on the weekends.
Yes, a lot of the odering problems are nursing staff related, but again....see that thread on Omnicare.
Most LTCs are unable to have standing orders or sliding scales for any med except for insulin.
As far as the poorly stocked E box situation...we have basic antiboitics, heart meds and a few other meds including narcs in our tackle box E Kit. Technically...we are able to use this for a few of the missing meds BUT...to use a narc you have to jump thru hoops and assuming that the med is in stock.
Using the coumadin example..what if you had a few pts that needed a different dose and you went to the ekit to get it? Our Ekit is only changed over by the pharmacy on M-W- F. We might have 10 1mg tabs...I have 8 people getting coumadin that might need adjustments....do the math...I don't have enough extra supplies to properly use the kid.
This has been an issue everywhere I've ever worked. I've been a nurse long enough that I've grown a back bone. I refuse to borrow. None of the responses I've read mention the pharmacy's responsibility in this. When we don't have a medication we need, it's their job to get it to us. I see that as part of their responsibility, like a doctor getting calls in the middle of the night, it comes with the territory. Pharmacies make big bucks on their LTC patients. Should nurses screw up and not reorder meds on time? Of course not, but when it happened, the pharmacy should have brought the med out.
When I've been told to borrow, I ask the pharmacist, doctor, DON, or whomever to show me in writing where it says that borrowing is OK. No one has persisted. If they did, I'd simply say, "so, you're telling me to do something illegal that could cost me my license?"
My state has yanked nurses' licenses for borrowing, saying there is never an excuse good enough. In some states, facilities can keep an 'emergency medication supply,' of certain medications. There are of course regulations for that too!
Borrowing is bad and it shouldn't be done. I think we all know that........
I will call the pharmacy and get it sent out ASAP BUT....ASAP might be hours if we are lucky. We do have a back up plan, but that only seems to be used on holidays and very rarely.
The noon run goes out and guess what time we get it???
Specializes in Gerontology, Med surg, Home Health.
we have basic antiboitics, heart meds and a few other meds including narcs in our tackle box e kit.
we can't take narc out from the e box or pharmacy won't send narc until pharmacy receive a prescription of that medicine. isnt that nice???
the pharmacy association or whatever they call themselves and the leaders of ltc are trying to get the law changed which would designate nurses in ltcs as intermediaries or some such thing so we could go back to doing things the way we used to. write to your congressmen and senators and governors and whomever else you can think of to get this done.
Specializes in OB, Peds, Med Surg and Geriatric Nsg.
OMG! I had the same dilemma last weekend about a Vasotec for a patient! The patient is uninsured and his pills are being brought individually by his son. Now he is the only resident that is on Vasotec 5mg. I called all wings to see if I could borrow one and all they have is Vasotec 10mg. I can't cut it on half because there is no line that says it could be cut in half. I can't call the pharmacy because the patient is individually bringing his medicine to the facility. So I had no choice but to Mark that I didn't give it (which is the truth) on the MAR. And wrote that it was unavailable. Now I feel like my ass is gonna get chewed to work today. Now, I feel like crying for being such a dumbass. I even told the incoming nurse about the inavailability of the Vadotec and she didn't said a thing.
OMG! I had the same dilemma last weekend about a Vasotec for a patient! The patient is uninsured and his pills are being brought individually by his son. Now he is the only resident that is on Vasotec 5mg. I called all wings to see if I could borrow one and all they have is Vasotec 10mg. I can't cut it on half because there is no line that says it could be cut in half. I can't call the pharmacy because the patient is individually bringing his medicine to the facility. So I had no choice but to Mark that I didn't give it (which is the truth) on the MAR. And wrote that it was unavailable. Now I feel like my ass is gonna get chewed to work today. Now, I feel like crying for being such a dumbass. I even told the incoming nurse about the inavailability of the Vadotec and she didn't said a thing.
I have done that before. I didn't get chewed out for doing so. Depends on your facility's policy. But what else were you do to besides marked that you didnt give it. You couldn't borrow as no one else was on it.
Asystole RN
2,352 Posts
not all the meds can be kept in an e-kit for the issues you described but 98% of the meds we give in ltc can...