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.
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.
Blue Devil, my point is that there some form of continuity of care with a licensed clinician or provider; you continue to do this yourself as you stated in your post, verifying my point.
As I stated, I worked in a group home that required nurses to be there to provide care; most of my practice has been in the community, NOT entirely in acute care or skilled facilities. My point was (and still is) that if there is a more than average observation- an acute CHANGE that is requiring more of a watchful eye, as in a licensed nurse to at least eyeball a patient ONCE a week, especially if they have wounds, at least to evaluate it, why is that unreasonable? If a medical error occurs, and the patient is harmed, it is the licensed person's responsibility; the issue is that when another person is practicing under a nurses' license, yet is grossly negligent, we are getting to a very dangerous point where it's not OK...it's NOT their license on the line.
That's why some people's hackles are up; if I was a nurse who's license was on the line in a group home that the OP was discussing in another thread (which this thread is about-a different thread) I'm not delegating under my license over the phone; I'm dropping by to make sure that it can be carried out safely; that wasn't occurring per the OP's posts in the thread-she was delegating over the phone, and the OP was not comfortable with it, either.
Again, if "skilled nursing"-that includes assessments and treatments and evaluation is needed more than usual-then it needs to be carried out by a licensed nurse, at least until the patient is at a baseline level, and that happens in home care, so why not in a group home, or at least in the group home that the OP from another thread? It's not improbable...skilled visits are done in shelters, heck, group homes, at least in my experience, even hospice services are granted; a nurse visits clients in hospice regularly; don't see a reason why a patient that is not at baseline can't receive services by a visiting nurse or checked on more often by the nurse employed by the group home.
I'm missing a rationale, or better yet, no one has given me a better rationale why a nurse shouldn't be following up with the team members who are delegated under the nurses license in person for acute issues for these patients, especially when people are missing meds as well as getting recurring wounds.
Again, this is about another thread where an OP is concerned about practicing outside of their scope, in a group home, as the OP of THIS thread has posted:
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.
Yes, but all those people were at home. I personally don't have a problem with group homes or adult foster care homes or the like having $9.00 an hour caretakers giving meds.
But, yes, the creation of "medication aides" in skilled nursing in ominous. As are the techs in hospitals. Anyone who doesn't see how this is bad for nursing is blind. If my skilled nursing residents could have their medication and treatment regimens managed and administered by just anyone, then why are they here? Why aren't they with their families? Or in assisted living? Or in adult foster care?
the bottom line is follow the money.......the residents in these group homes are not and never will be productive members of society, and are being treated thusly. The quicker they die, the more money saved.
Yes, but all those people were at home. I personally don't have a problem with group homes or adult foster care homes or the like having $9.00 an hour caretakers giving meds.
But, yes, the creation of "medication aides" in skilled nursing in ominous. As are the techs in hospitals. Anyone who doesn't see how this is bad for nursing is blind. If my skilled nursing residents could have their medication and treatment regimens managed and administered by just anyone, then why are they here? Why aren't they with their families? Or in assisted living? Or in adult foster care?
I'm not pretending to know anything about geriatric or SNF care. So please don't take my word for anything. But isn't this slippery slope argument prevalent in most of health care these days? You have MDs wondering where they fit into the puzzle when a patient can see a mid-level for 1/3 the cost. And that's just outpatient. Who wants to see a psychiatrist when a psychologist can rx meds? What about RTs and PT/OTs being used in acute and ICU care to place central lines and change complicated dressings?
I had job security in mind when I made my original reply because I want to keep my job as much as anyone. But I find it a bit disingenuous when people argue patient safety for things that aren't really patient safety related -- it's all about job security. Would using the highest qualified person to provide a certain level of care of *best* for the patient? Certainly! Does it happen? No, not usually and most people get through it just fine.
Ah, well this was a nice little gem to stumble upon - a direct link to my thread with disgust. Lovely.
Like it or not, I'm still a nurse delegated CNA right now, so when some of you act so greatly disturbed, angered and frightened over this, it's like you all view ME in that light because I'm one of those CNAs who holds insulin in their hand.
Some of you are making it really difficult to tell whether you're upset at both me and the situation, or just purely the situation (and how the state allows it).
I'm not pretending to know anything about geriatric or SNF care. So please don't take my word for anything. But isn't this slippery slope argument prevalent in most of health care these days? You have MDs wondering where they fit into the puzzle when a patient can see a mid-level for 1/3 the cost. And that's just outpatient. Who wants to see a psychiatrist when a psychologist can rx meds? What about RTs and PT/OTs being used in acute and ICU care to place central lines and change complicated dressings?
I had job security in mind when I made my original reply because I want to keep my job as much as anyone. But I find it a bit disingenuous when people argue patient safety for things that aren't really patient safety related -- it's all about job security. Would using the highest qualified person to provide a certain level of care of *best* for the patient? Certainly! Does it happen? No, not usually and most people get through it just fine.
Yes, you've got a point. I've admitted in other threads that my stance on medication aides and hospital techs has at least partial roots in nothing more than thinking about my own livlehood.
What's more, I'll even conceed that there's a certain amount of humorous irony in that stance when I turn around and support roles for practical nurses and the team nursing model.
But what I think people unfamilar with skilled nursing don't realize is that the acuity of our patients has increased. It's not a home for the little old grandmas who just need a few pills and a brief change. It's post ops, complex wounds, IV ABX, and so much more. The gap between SNF and med/surg isn't as wide as most people think.
I see people talking about UAP administering injections in clinics as if that's comprable or somehow justifies UAP passing meds in higher acuity settings. Apples and oranges.
Putting aside my instinct to protect my job, this still isn't something to be taken lightly. Anyone who knows anything about LTC knows that the amount of time these patients spend with licensed nurses is already minimal. The vast majority of the nursing care is provided by CNAs. By introducing med aides, they're going to cut the nurse/patient ratio further. The whole point of med aides is to decrease the number of nurses.
And anyone who says "well it's a waste of money to pay nurses if all they do is pass pills" doesn't know what a LTC med pass is like. With any good nurse, there's a whole slew of assessment and intervention that goes on during med pass. I identify illness and emergent status changes all the time while passing pills, often having to call the phys. and have the resident sent out. The day where my med pass is spent "just" passing pills hasn't happened yet.
And if we're going to allow medication aides in SNFs, we also might as well change how we define "skilled nursing" altogether. Because CNAs administering medications ain't skilled nursing.
We are trained that if their blood sugar appears low, give them some juice or something, wait 15 minutes and test again. If it doesn't improve, call the manager immediately. Of course as you know this is all relative to the time of day, too. I would expect it to be low upon waking in the morning, that would not surprise me.
If it appears too high, we give them a glass of water, have them walk around/ambulate, and take it again in a few minutes. Same procedure if no change.
In the chart notes when we put in blood glucose results in the eMAR, a warning pop-up always comes up that says, "Notify the manager immediately if the blood sugar is above/below x amount." Those values are taken from their doctor's established parameters for them.
There is only one resident that receives insulin and her insulin is given off a sliding scale, which is posted in the med cabinet. Which I why I say giving insulin is an easy task for me to do for this particular client, IMO. I test her glucose level with the glucometer. It gives me the value. I look to the chart and it tells me within the value range how many units to give. I give/do not give the # of units depending on the blood sugar value.
Ambulation and glasses of water will do exactly nothing to make a blood sugar that is too high go any lower.
With all due respect, THIS is exactly why someone who is not a licensed nurse, who has taken just a 9 hour online course in medication administration is dangerous.
Just because one believes they CAN do these things, doesn't mean they should.
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.
In actuality, I am appalled that there's obviously higher level of care that is needed than a group home/assisted living can or should provide. (See bedbound/wound part of OP's original thread).
I am further appalled that because of whatever reasoning, family has chosen to have their elderly relative put into a home situation because (usually, anyways) they require more constant care than anyone can give them in their own homes.
That the company alludes to nursing care, however, the nurses in fact "delegate" what should be a nursing judgement call onto unlicensed people with little education for their "certification".
The OP and her coworkers may be empowered to do these things, however, it is the RN who puts their own licenses at risk for UAP's to be doing various nursing tasks that require assessments. Because that is what the family is paying for. Otherwise, they would have private duty at home. Or their relative would be in skilled care/nursing home.
My entire issue with this situation is that it appears that families are lead to believe that the level of care is different than what in actuality it is.
I am curious as to if the RN says "you are NOT to do any nursing task with the residents I am responsible for" and they actually go into the home themselves and do their own assessing, medication administration, diabetic interventions....but from the information that has been given, this is not the case. But I am quite sure they bill for "RN" skilled care.
Ah well this was a nice little gem to stumble upon - a direct link to my thread with disgust. Lovely. Like it or not, I'm still a nurse delegated CNA right now, so when some of you act so greatly disturbed, angered and frightened over this, it's like you all view ME in that light because I'm one of those CNAs who holds insulin in their hand. Some of you are making it really difficult to tell whether you're upset at both me and the situation, or just purely the situation (and how the state allows it). Regretting sharing this at all.[/quote']
As stated before, most, if not all who are concerned are not concerned about your role per se-you are not at the fault of what a company tells their clientele-it's more about the patients that may need an extra level of care.
When complex care is needed and involved, it ones beyond the tasks; there is that extra assessment and decision making is involved; you are not in the position to make those because you are not a licensed professional, yet, based on your OP, you stated your lack of comfort for this.
Now, the OP of this thread:
Disturbing is an understatement. As an addendum to the "Nursing Glut" thread I'm going to go ahead and cross post this here. Mods feel free to move this, but I think the topic warrants as much exposure as possible. Absolutely frightening on so many levels...patient safety, and the rapidly changing definitions of the nursing profession itself. What insanity are we experiencing when nurses in one State are handed a mop and a bucket, and in another state the CNA's are handed an insulin syringe? https://allnurses.com/nursing-issues-patient/couldnt-believe-he-881366.html
The OP was discussing the ever increasing "history repeating itself" circus that is happening in some parts of the country; to be fair, the Vanderbilt story should be attached; however, when most who saw you thread decided to focus attention on the issues that you experienced, most if us decided to look at it more closely. This has happened before in the history of nursing, much to the patients detriment; as clients are having increased complexity, we are, for the most part concerned about knowing these changes immediately for the sake of patient safety; the most paramount aspects of being a licensed nurse is to provide safe, effective care.
While some think CNAs should not be in a position to do certain tasks, that's their prerogative, and most likely from a previous experience that may have led to complications, or never worked anywhere where CNAs had expanded tasks where needed; I used to hear people say this in front of me as a CNA and as a LPN; I didn't take it personally; it was a matter if not knowing-there were posts enlightening those posters.
You have a right in your OP to be concerned; as you progress through you schooling, you will come back to these posts and have a better understanding in terms of what most of us are talking about:
I know that many RNs do not have the best outlook on nurse delegation and I understand those feelings
When you posted this comment from your subsequent comment on your coworker:
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!
^ That's how most of us feel EVERYDAY with our licenses when something is missed, or a risk of pt care safety is on the line. To have that in the hands of someone who has NO accountability that is under out LICENSE -NOT the patients or family members; I repeat NOT the patients or family members-carries the SAME feelings, hence the posts...it looks like you will be in the same camp-based on your post you are already there
You coworker is one who doesn't know better; one of the major morbidities and mortalities committed in healthcare is failure to rescue and med errors-something that we are concerned with every day because of our responsibility; he doesn't feel the responsibility because he doesn't have a license.
My adage is: one can never detect TONE from a post; if anything I've seen nurses explain to you why there is a need for licensed nursing; and in some posts you felt offended; yet as I posted you state that you understood; now which is it???
In any event, the posts are more towards the issue, not at you.
My adage is: one can never detect TONE from a post; if anything I've seen nurses explain to you why there is a need for licensed nursing; and in some posts you felt offended; yet as I posted you state that you understood; now which is it???
In any event, the posts are more towards the issue, not at you.
It got really confusing after awhile.
I still overall understand the general frustrations on the topic and even agree with them, that hasn't changed. But I can still feel offended at the wording people choose to approach me with. I really appreciate those who would mention that they feel I'm a responsible CNA, that I did the right thing, but that [insert honest feelings on the topic here]. That is constructive, and doesn't make me feel defensive.
Others were not as constructive, and made me feel like my competence was being questioned in the spotlight - which is a demeaning feeling. I still have this job (for now) and I do well at it. I may not be an RN and do assessments/acute care/etc, but I am also not a complete neanderthal either.
LadyFree28, BSN, LPN, RN
8,429 Posts
Blue Devil, my point is that there some form of continuity of care with a licensed clinician or provider; you continue to do this yourself as you stated in your post, verifying my point.
As I stated, I worked in a group home that required nurses to be there to provide care; most of my practice has been in the community, NOT entirely in acute care or skilled facilities. My point was (and still is) that if there is a more than average observation- an acute CHANGE that is requiring more of a watchful eye, as in a licensed nurse to at least eyeball a patient ONCE a week, especially if they have wounds, at least to evaluate it, why is that unreasonable? If a medical error occurs, and the patient is harmed, it is the licensed person's responsibility; the issue is that when another person is practicing under a nurses' license, yet is grossly negligent, we are getting to a very dangerous point where it's not OK...it's NOT their license on the line.
That's why some people's hackles are up; if I was a nurse who's license was on the line in a group home that the OP was discussing in another thread (which this thread is about-a different thread) I'm not delegating under my license over the phone; I'm dropping by to make sure that it can be carried out safely; that wasn't occurring per the OP's posts in the thread-she was delegating over the phone, and the OP was not comfortable with it, either.
Again, if "skilled nursing"-that includes assessments and treatments and evaluation is needed more than usual-then it needs to be carried out by a licensed nurse, at least until the patient is at a baseline level, and that happens in home care, so why not in a group home, or at least in the group home that the OP from another thread? It's not improbable...skilled visits are done in shelters, heck, group homes, at least in my experience, even hospice services are granted; a nurse visits clients in hospice regularly; don't see a reason why a patient that is not at baseline can't receive services by a visiting nurse or checked on more often by the nurse employed by the group home.
I'm missing a rationale, or better yet, no one has given me a better rationale why a nurse shouldn't be following up with the team members who are delegated under the nurses license in person for acute issues for these patients, especially when people are missing meds as well as getting recurring wounds.