I work as a nurse delegated CNA in a very small adult family home that is state certified and actually takes place in a big house, not a facility. It's actually a pretty neat set up as it truly feels like you're in a comfortable home and not in an institution. That said, because we are super small and independently operated, there are only two CNA's on staff and that's it. No RN's, no doctors, no anything. However, we do not administer anything beyond oral medications and insulin injections. We don't take anyone in need of acute care, so it's not a place designed where nurses must be present at all times anyway.
So, my schedule recently changed since I'm in school and I now work with someone who has a lot of experience in LTC (20+ years) and has been working for this company from its beginnings (which is still fairly new, less than 5 years in operation). He is a nurse delegated CNA like me. I am a new CNA, but personally? I don't like to work with him. He does things "his" way rather than what is normally expected and it drives me nuts as I am the type of person that likes to follow rules and regulations to the letter, especially when it comes to other people's health. He does a lot of little things that bother me, such as having the diabetic patients already eating before he takes a supposed fasting glucose test, is very vague in chart notes (says someone ate and drank "adequately" instead of giving measurements/ratios), things like that.
To make a long story short, he made a major med error by giving a resident someone elses meds. My heart dropped. I understand people make med errors, but that to me is a HUGE error. I always follow the 5 rights because I am paranoid of this exact scenario potentially happening, so I do everything in my power to not let it happen when I am the one administering. But more disturbing than this is that he didn't make a big deal about it at all. In fact, it was as if nothing happened. I said that I was calling the manager to tell them right away of the incident. He says, "Oh, don't worry about calling her. It's not a big deal. I'll just chart about it later. And anyway, it's not like the medications that this person is taking will effect the other person adversely anyway."
I felt my heart pulsating violently in my chest in anger. Does RN, MD, or PhD follow your name in any way, shape, or form? Are you a pharmacist or pharmacy tech? If the answer is no, you don't know JACK about how that medication well effect that resident! This is the kind of error that could potentially kill someone! And to have no sense of urgency is just...I couldn't believe it. Oh, and he didn't even chart it. This whole thing was just so, so wrong. He should have known better. It shouldn't have even been a hesitation. The fact that he didn't even want me to call and to just keep it quiet...OMG. No. I advocate for my patients, thank you very much, and to hell if I was going to just sit back while a resident has someone elses meds pumping through their system with no one speaking up for them!
I only had a few minutes left on my shift when this all went down, and decided that I was going to call the manager immediately after getting off to tell them what happened and I did. They were shocked and appalled and both the manager and the owner drove to the home that night to address him. They called me while I was home, put me on speaker phone so he could hear me, and I explained the entire thing from beginning to end. The owner asked him if my account was accurate, and to my surprise the CNA said yes, everything I said was true and accurate.
I am not sure what disciplinary action happened, but it's going to be extremely awkward when I have to work with him next shift. Ugh.
Specializes in Certified Med/Surg tele, and other stuff.
Correct. We are essentially working off of her license.
There is no medication we give that is "pre-done" by any RN. The morning, afternoon, evening, and bedtime meds are all separated in their bubble packs. We take them out, crush them, mix in applesauce and administer. For liquids, the only liquids we deal with right now are laxatives and one resident receives liquid potassium. They are measured in mL, mixed in their glass at dinner with juice, Ensure or milk (depending on the resident) and administered. We also administer PRNs and need to use judgement calls. We work with residents with severe dementia and a couple of them in particular are prone to outbursts. I find myself administering PRNs of risperidone, trazodone and a topical cream of Haloperidol. Other PRNs include narcotics for pain such as oxycodone, laxatives for constipation such as senna and MoM, etc.
All of our residents will take their own meds in the event that we spoon feed it to them, but otherwise no, they can't take it on their own. They're too confused. Only one cannot walk on her own and that's because a few years ago she broke her hip and is terrified of standing. She needs to be transferred for everything. She is the one who gets the bedsores. We do move her around a lot, transfer her to new places in the house frequently, use pillows to releive pressure, but sometimes they do come back. I am not delegated for wound care and am not in a hurry to speak up to be delegated for it either. The one who receieves insulin can never do her insulin on her own. She is the most far gone from dementia out of all of them. I would never want an insulin pen in her hand...I shudder at the thought (she is also the most violent, so I certainly don't want her in control of a small needle!)!
What ****** me off is that I feel like I am being used from my company. I've only been working here for three months and I have all these certificates, and I was started at $10.00. $10 flippin' dollars. It's so much work, so much for two people to keep track of at once, and is a 40 minute commute. They can never afford to have an RN present. They can't even afford to give us any benefits at all. We work holidays, like Thanksgiving and Christmas, and are not paid a cent more for being there those days. Oh, and forget health care benefits, even when you're full time. I'm so uncomfortable being there and the feeling grows each day I work there.
I do feel at times that we are working outside of our scope, but in our state it has become the norm for CNA's to be delegated. It is now part of CNA training. However, I still think our home asks way too much of us for far too little. Not only that, but insulin and FBS is one thing...I would agree that wound care is an entirely different animal that I don't feel comfortable getting involved it. I don't feel comfortable making assessments and such on it, which is what we do. A nurse will be called to come out to look it over and suggest what we do from that point, but beyond that we are the ones in control, not the nurses. And based on my coworkers, that's scary.
I was angry yesterday when a coworker from a previous shift forgot to administer a medication as it was still sitting in its bubble pack slot. I call the manager to inform her. Manager questions the coworker. The coworker says it was rejected from the resident. Ummm...it's still in the bubble pack, meaning it wasn't crushed, meaning it wasn't offered in the first place. Idiot. Way to try a pathetic attempt to cover your tracks for forgetting. These mistakes happen way too often and I want out. I hate that I even have to put in a two weeks notice and endure another second of the mayhem. I especially dread my next shift where I face that guy. Idk how he will treat me, whether he will be professional or not. And I also dread this shift because the workload is not evenly distributed. He does the cooking, cleaning, laundry. I do the transferring, toileting, the changing of clothes, etc. By the time my shift is over I feel dead. I get that he has a bad back, but it's not fair to put all that work on me!
Tomorrow I am giving Fred Meyer my resume and cover letter in person. Yes, a grocery store. Why? Because I want to milk a "simpler" job for all it's worth while I'm still in school (I worked in a grocery store for two years while being in high school and I enjoyed it a lot). And I only make $10.50 now (minimum wage here is over $9), so...yeah. A job in a grocery store that is flexible with my nursing school schedule, pays slightly less but is super close to where I live and requires much less responsibility? Yes please!
I have never heard of a CNA in my area making what I make, and they don't even have the certs that I do. And I've already looked into CNA positions that aren't only LTC (working with the elderly is not my calling, I have discovered) and they weren't biting. Tried hospitals and said I was a nursing student in the hopes that that would persuade them and still no bites. I just don't have enough experience like they would like, and I'm only a first quarter nursing student. But it's fine, I would be happy with Fred Meyer right now. :)
Good for you for seeing the disparities going on. Good luck at Freddies. I thought about working there too and quit nursing!
I have heard of CNAs putting in foleys and I would take up less issue with that than I would CNA's administering insulin. In my Sim Lab at school when the patient went into a hypoglycemic crisis some of the students wanted to give the patient more insulin. In the real world that is just not compatible with life :/
To be fair the meds are PO. It's not like they're reconstituting IV antibiotics or titrating pressors. Lay people pass oral meds all the time in their own homes. When I was still in nursing school I worked in group homes and the aides could be "med certified". The insulin is a little more scary, but, again, non nurses inject themselves and their children all the time. A lot of the companies make their devices really user friendly and straight forward.
The only thing that's missing is the education, critical thinking, and assessment skills behind passing the med. This is the problematic part.
My diabetic niece was dosing and injecting herself with insulin by the time she was eight or nine. It's not rocket science. People take PO medications all the time at home. I think at one time I was managing 12-15 pills a day, myself, and I was a teenager. I somehow managed to not kill myself despite not being able to rely on a skilled nurse. Parents of special needs kids are expected to be more than competent in all nursing skills when they take their kiddos home -- everything from emergency trach changes to trouble shooting ventilator alarms.
My diabetic niece was dosing and injecting herself with insulin by the time she was eight or nine. It's not rocket science. People take PO medications all the time at home. I think at one time I was managing 12-15 pills a day myself, and I was a teenager. I somehow managed to not kill myself despite not being able to rely on a skilled nurse. Parents of special needs kids are expected to be more than competent in all nursing skills when they take their kiddos home -- everything from emergency trach changes to trouble shooting ventilator alarms.[/quote']
True, however, there's more to this thread; there are people who are assessing the residents for agitation, and giving them meds; agitation can also be an indicator of infection; hence, there is a possible miss or a possible delay in care that would not occur if there was a nurse actively visiting and assessing the patients, heck at least TWO days out of the week, and one weekend day. Wound care is being performed-measuring, staging, etc is occurring without a nurse present. A med error even occurred.
Most people (as well as kiddos) who need skilled visits at least have home care, either visits or private duty-in term of kiddos there are appointments that need to be adhered to to prevent complications....they don't go home and then, "see you in two years!" type of thing; it's a "health promotion" stand point with continuous monitoring occurring because of the health issues...the patients described in the OP of the thread we are discussing need at least and extra set of educated licensed nurse eyes on the residents-the nurses are having the ultimate responsibility while not even LOOKING at the patients.
Thank you so much for being so calm and considerate in your replies on this thread. Obviously this is a hot-topic and some posters may sound as if they are attacking you, when they are just appalled at the situation.
Thank you also for bringing the type of 'delegation' up for discussion. I, for one, had never heard of such a practice and do not support it. Perhaps your thread will energize each of us to watch our state nursing regulations carefully and to actively protest any move to 'delegation' where we practice.
About the insulin administration - we educate people every day to go home and do exactly what you have been taught: monitor daily BGs, administer insulin per sliding scale, eat correctly, etc. Most of the patients and families we educate have no medical background or training at all and yet we do not insist that a registered nurse appear in their home each time they need insulin.
It sounds like you really care about patient safety and that you have a strong sense of working within safe boundaries. I wish you much success with your nursing studies and thank you again for bringing this topic to our attention.
I don't have any problem with what the CNA is doing here, in principle. It isn't acute care. If patients and family members can administer, so can CNAs.
And we all know if we randomly picked 10, 100 or 1,000 RNs from any med-surg floor in America and gave them an exam on the pharmacokinetics and dynamics of the various insulins and oral antiglycemics, most would bomb. Don't pretend the average nurse knows more than what insulin is for in the most general sense and how to administer it. Let's be serious.
I am all for advocating for the profession, but let's not gang up on this kid just because she is doing the same thing hundreds of thousands of non-med professional people do everyday without killing anyone. That does nothing to elevate nursing. It just makes Nursing look petty and insecure.
I for one, will not teach a CNA to admin meds and inject insulin. No way, no how. I worked too hard to get my education /license too pass it on.
P.S. thanks for doing the right thing. Good for you!
That's a shame. I could not disagree more with this sentiment. I will share my knowledge and skills with any able person and teach them to do anything they are willing, anytime.
You're allowing yourself to be used. Either speak up and possibly get results or be quiet and get no change. If you speak up and they don't change or treat you badly write a courteous resignation letter stating why you are quitting ....don't be emotional, just factual.
"I don't believe I can continue in this position due to x, y, z. As much as I appreciate having been hired, x, y, Z. I believe this is in my best interest and wish to quit effective 10-**-13
SINCERLY,
Name, Credentials
Oh Em Gee. Would you listen to yourself? This kid should quit her job because you don't like what she is empowered to do?
OP, don't listen to this. This thinking comes from the fact that Nursing is feeling threatened because as a profession, it will not step up and do what must be done to save it (namely, force higher educational standards). That is not your problem, and I would not for one minute let it interefere with your present employment situation.
I have a patient that is cognitively challenged, with an IQ in the 70s. She is a type 2 diabetic, lives alone, does all her own shopping,cooking, etc. She has a major clotting disorder as well. And yes, she gives herself her own enoxaparin injections, levemir and sliding scale insulin all by herself. She has been administering the insulin for more than 20 years, and the enoxaparin for at least 3 years that I know of. No adverse events.
Why can't CNAs, presumably of "average" intelligence do as much as my patient?
Ignore the politics and let go of your natural instinct to say "only a nurse..." because we all know anyone can be trained to perform these skills. It doesn't take anything extraordinary on the part of the learner, other than commitment. Case in point.
True, however, there's more to this thread; there are people who are assessing the residents for agitation, and giving them meds; agitation can also be an indicator of infection; hence, there is a possible miss or a possible delay in care that would not occur if there was a nurse actively visiting and assessing the patients, heck at least TWO days out of the week, and one weekend day. Wound care is being performed-measuring, staging, etc is occurring without a nurse present. A med error even occurred.
Most people (as well as kiddos) who need skilled visits at least have home care, either visits or private duty-in term of kiddos there are appointments that need to be adhered to to prevent complications....they don't go home and then, "see you in two years!" type of thing; it's a "health promotion" stand point with continuous monitoring occurring because of the health issues...the patients described in the OP of the thread we are discussing need at least and extra set of educated licensed nurse eyes on the residents-the nurses are having the ultimate responsibility while not even LOOKING at the patients.
These people must have primary care providers or they would not have prescriptions for medications to adminster. I have many patients in these type of living situations, and they are sometimes the perfect solution to a less than ideal home situation, and usually preferable to nursing homes. Patients come into the office with a caregiver from the home and I assess the patient, make a diagnosis, come up with a plan and explain verbally and in writing what is to be done. It is not a big hairy deal.
You guys needs to take off the acute care glasses and remember that in-hospital care is barely the tip of the health care iceberg, lol. Only a miniscule percentage of people are in in-patient settings. Most health "care" happens outside of institutions, and group home situations can be excellent. No nurses required.
tokmom, BSN, RN
4,568 Posts
Good for you for seeing the disparities going on. Good luck at Freddies. I thought about working there too and quit nursing!