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.
I'm reposting the replies that seemed to touch a nerve for you:
How can you be "nurse delegated" when there is no nurse delegating these tasks to you? And I am with Guttercat. I want the person giving me my meds knowing more than just the 5 rights. It's commendable that you haven't made a med error...yet. If you're giving that many meds eventually you will make a med error. The best nurses have made medication errors. Knowing how to handle the error, beyond just calling someone to report it, is what distinguishes you.[/quote']
That's it?!? And no disrespect, but insulin administration and management of the diabetic patient is not "easy." It's serious business. Screw up and you can kill or irreparably harm the patient.
Sorry but your certifications do not trump state and federal regulations. If they (surveyors) ever come in to evaluate this place and discover you're in a nursing student, you could find yourself in a lot of trouble if they determine you were doing things you were not supposed to be doing, like assessing patients, for one. Your could find your dream of being a nurse going up in flames. There are LPNs in certain areas who don't make much more than you do, and they are nurses with licenses.[/quote']
OCRN63 is correct in her responses, even regarding the law that is in your state; your employer is REALLY trying to stretch a loophole here; if anything she's giving sage advice. There isn't any address of your credibility, or even an accusation of a lack thereof.
I've stated that while nurses are not there 24/7 they come in periodically for delegation purposes and then delegate you (if they havn't already done so). I have been personally delegated for everything I do now. However, the nurse was comfortable delegating me over the phone and not in person for wound care (which I already explained I wasn't comfortable with as it didn't seem quite right to me, so though she quote "delegated" me no, I don't consider myself delegated for wound care and do not take on any wound-related responsibilities). * And no disrespect to you, but just because I find a physical task to be easy* for me to do and understand does not mean that I do not find the task itself serious or take it lightly. I find this comment to be demeaning and insulting. First of all, I did not post acting as if my delegation learning was above any kind of regulation. Second, WA ALLOWS for these tasks to be done by CNAs as I've already stated numerous times, so where is the "trumping of state and federal regulations" happening? WA has state-certified classes designed specifically for CNAs to be certified to do these things, be nurse delegated for them and then do them without a nurse present. That is not against state, that's doing what the state seems to want us to do. Look at WA cirriculum for nurse assistant delegation. It's all there. Like I said before, why WA allows all this is beyond me. I have no idea. Yeah, I get the thing about LPNs, and that is unfortunate. But again, that is not my fault. That is an issue of the state, for they think it's okay to have CNAs do similar tasks. Which is why I already said to a PP...if you're angry about it, your focus of anger is at the wrong party. Do not condemn us nurse delegated CNAs for doing our job in which our state allows and certifies us to do. I do not see the point in that. I was trying to find my first CNA job and this job contacted me. I needed to be delegated in order to take it, so I did what I had to do and took the job. I did not know what I know now of really ALL the responsibilities I would be expected to have and how taxing that would be on me for just being a CNA, otherwise I wouldn't have taken it. I just wanted to get some sort of experience somewhere, and being fresh on the healthcare scene, only had a superficial understanding of all of this. I didn't even know I could be delegated for these things until I found out about it through this job (the CNA cirriculum to allow delegation changed after I took the class - now it is the norm). I feel like you're either missing or skimming over the parts where I am saying that I agree that nurse delegation of this magnitude should not happen as there is far too much risk in our hands. I also said numerous times that I'm trying to find another job that has nothing to do with the work I'm doing now - to get out while I still can. I already answered this question from someone else and am not going to repeat myself. All of your responses in regards to me doing my job sounds accusatory, or as if you as the RN are trying to put me, a non-RN, "in my place." I refuse to be put to some sort of chopping block, especially since I have well acknowledged the responses already made here. This is at least how I interpreted your comments, and it offends me.[/quote']
Where I starred is the rub...and I understand the reponse from OCRN63; insulin is far beyond the physician tasks; it is a high alert med; one that is along with your post about potassium, is a high alert med:
Do you want to know what's truly horrific? We have a resident who has one kidney and cannot eat foods with potassium. However she receives a laxative that comes from a bottle that looks JUST LIKE the potassium bottle. One slip of the hand in the wrong glass and she would be dead - or close to it. Granted, we have it labeled "POTASSIUM!!!" all over it but given the track record of this place and the bright minds I work with... I hope Fred Meyer hires me... I have lots of relevant experence for them, 4 years worth![/quote']
If you feel that way about the potassium; I sure you feel the same way about insulin.
These patients , as you even stated cannot even give their mediations competently as the satute states; you have given us examples of that you are caring for individuals that are a tad bit more acute and need a licensed eye on them more periodically.
Again, no one is calling you incompetent; you are practicing out your scope as you even stated; if the State and Feds were called in, even from another co-worker, and you were doing something outside of the scope that required an assessment, there would be a possibility that you career would be over before you start, as OCRN63 has stated; that does occur, unfortunately; in my state two CNAs, who were nursing students were recently in this situation; now they are unable to work as licensed nurses because of practicing outside their scope; one is prohibited from being hired in a Medicare-approved facility.
Your state law also states that you can also decline to be delegated without reprimand as well. I am sure you will use that judgment as needed moving forward because of this teachable moment.
Ore than anything; we are upset that if anything were to occur against you, you will LOSE the opportunity to join us in this business; and that would not be fair to you at ALL; and it would because of a business trying to get the bottom line, no more no less.
I won't disagree that OCRN63 was incorrect in what they were trying to get accross to me. However, they could of done it in a way that didn't sound like the were reprimanding me like a child in gradeschool.
Again, I felt like they were coming from a position of them being the RN putting me, the non-RN, in my place. Not cool. Could have said the same things without some of the intended underlying sting to go with it in order to make a point.
I won't disagree that OCRN63 was incorrect in what they were trying to get accross to me. However they could of done it in a way that didn't sound like the were reprimanding me like a child in gradeschool. Again, I felt like they were coming from a position of them being the RN putting me, the non-RN, in my place. Not cool. Could have said the same things without some of the intended underlying sting to go with it in order to make a point.[/quote']
There are going to be people, managers, instructors, doctor that want to emphasize and enlighten; and it may and will sting; however, maybe it's me but I think you do understand the gravity of the situation that your in....I think that's what truly stings, more than the words that have no tone whatsoever across a screen.
There are going to be people, managers, instructors, doctor that want to emphasize and enlighten; and it may and will sting; however, maybe it's me but I think you do understand the gravity of the situation that your in....I think that's what truly stings, more than the words that have no tone whatsoever across a screen.
I probably would not be nearly as sensitive if I didn't have this job anymore. It's just not a good feeling when you're in school to be an RN and the RN's you look up to are revolted at what you do in your workplace. How else am I supposed to feel but sensitive?
I can't get another job until I have another one lined up - I can't have a break in money coming in. It needs to be continuous. And it's hard to job search well when I'm bound by my nursing school obligations. Tomorrow I have my Return Skills Demonstration on the chest/lungs assessment and I'm spending all day today getting prepared for that.
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.
My turn to be condescending with all due respect. Not for nothing, but this is evidence based rationale. Exercise decreases serum glucose and adequate hydration helps optimize pancreatic function and performance of endogenous insulin. The fact that you apparently didn't understand this speaks to my earlier comment that most nurses know almost nothing about the pharmacokinetics and dynamics inherent to diabetes care. smh
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.
You are quite sure, are you. I'd wager you are dead wrong about that. Can I see some facts to back up this ascertation?
The OP did not describe a single component of care that we know factually requires something beyond a group home environment. I submit that you simply have no understanding of outpatient care, and specifically the level of care group homes provide. They do all of these things, routinely, all over the country. The patients are assessed by, and the plan of care still comes from, a provider. Care is just implemented by someone other than a nurse, which in the described scenario sounds perfectly appropriate given what we know. It does not take a rocket scientist to change a piece of duoderm.
The tasks do not require assessment or nursing judgement. They require clear instructions from a licensed provider, and minimal training. The ONLY reason to for nurses to grasp onto these low level skills like a life line is to continue to justify the outrageously low level of education required for entry.
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.[/b'] Just because one believes they CAN do these things, doesn't mean they should.
Omg, wow - I almost missed this! Thank you BlueDevil,DNP, for pointing this out.
Jadelpn, even just a quick Google search would attest that I am not incorrect. Not to mention that this is what the RNs have instructed me to do.
Silly how, because I'm not a licensed nurse, I don't have the capacity to understand even the most superficial aspects of health concepts...
I believe the best use of this topic is not to divide us, but to keep dialogue open. All of us in the medical field (RN, LPN, Provider, CNA, MA, ancillary, specialists, ad infinitum...) should strive to be as ahead of the game as is possible on the trendings. (I think we can all agree trendings are fiscally based.)
A knowledgeable body of medical caregivers is an empowered body. Otherwise "stuff happens" and decisions/laws are made while the rest of us--in the words of a poet--"sit 'round and pluck blackberries."
Anyone entertaining the notion of entering (or advancing in) the medical field needs to keep abreast.
As a side note, I see many more MA jobs posted at hospitals than ever...with a (vague-ish) job description that entails much of the same that is required of RN's (including IV/meds/cooordinative care on the floor...)
Not saying it's "right or wrong," but, I'm asserting that the face of the nursing profession is changing rapidly, and right under our noses.
My turn to be condescending with all due respect. Not for nothing, but this is evidence based rationale. Exercise decreases serum glucose and adequate hydration helps optimize pancreatic function and performance of endogenous insulin. The fact that you apparently didn't understand this speaks to my earlier comment that most nurses know almost nothing about the pharmacokinetics and dynamics inherent to diabetes care. smh
"Mostnurses?" That's a pretty broad brushstroke, BlueDevil.
You may/may not be right/wrong, but way to go all anecdotal on us.
But, for posterity, let's say an LOL in a "group home" receives a coverage amount of insulin after breakfast and the AM glucose readings (administered by "Whomever UAP Caregiver"), and then the LOL decides they want to join in on the morning's group exercise-activity. The LOL gets a little lightheaded while throwing the ball around, maybe even a little bit confused and unable to express their subjective symptoms.
Who is more likely to put two-and-two together and act on it, the CNA with a nine hour online medication course, or the RN?
"My turn to be condescending with all due respect. Not for nothing, but this is evidence based rationale. Exercise decreases serum glucose and adequate hydration helps optimize pancreatic function and performance of endogenous insulin. The fact that you apparently didn't understand this speaks to my earlier comment that most nurses know almost nothing about the pharmacokinetics and dynamics inherent to diabetes care. smh"
Wow... and I will be condescending to you and your "highly educated" self, while I am asking granny with the 350 blood sugar to just get on up and do some exercise and have you a glass of water while you are at it granny, never mind your dizziness and confusion that goes along with hyperglycemia, the book says running you around and forcing H20 will bring it on down.... That will go over well. Have you gotten so educated and that you don't remember real life isn't always "evidence based"?
My turn to be condescending with all due respect. Not for nothing, but this is evidence based rationale. Exercise decreases serum glucose and adequate hydration helps optimize pancreatic function and performance of endogenous insulin. The fact that you apparently didn't understand this speaks to my earlier comment that most nurses know almost nothing about the pharmacokinetics and dynamics inherent to diabetes care. smh
In acute care, the last thing we would do is ambulate and give water. There are order sets and if a patient is on a sliding scale, this would be the time to use it. Acute care evidence based practice is to medicate accordingly. And if the blood glucose is too high, then perhaps a patient is at risk for a seizure, so ambulation would not be my first choice. And one could assume that the people who are paying top dollar for a home enviroment for their loved one would be far more condescending to an acute situation being dealt with other than medicating accordingly far worse than I.
Not to mention the resident who is bed bound. Wound care should always be assessed, re-assessed and pain control given accordingly.
Bottom line is that regardless of the level of education, regardless of the regulations, regardless of who is appropriate for a home enviroment--someone screws up and who pays the price.....The RN on the other end of the phone.
Even the Op herself states that there's something wrong in this situation. And I happen to agree.
LadyFree28, BSN, LPN, RN
8,429 Posts
I'm reposting the replies that seemed to touch a nerve for you: