Dealing with possibly unsafe coworkers?

[Oswin]

I am worried about one of my fellow nurses. Primarily, I am worried about her ability to care for her residents appropriately. On multiple occasions I've been told of an issue that was reported to her that she didn't investigate (residents with new pain, behavior changes, abnormal vital signs, difficulty breathing...) about the only thing that gets her attention is chest pain or a fall, it seems. I remember once a CNA told her a resident was SOB and was out of oxygen during a meal. She was doing a med pass and told him he'd have to wait until she was done passing pills... They came and got me and his pulse ox was 78%... I refilled his oxygen; she was no where in sight. Another time she presumably assessed someone the CNA said wasn't acting right and came to the determination that the resident was tired. The CNA came and got me a while later when the resident still wasn't acting right and the resident had new hemiparesis, new slurred speech, and was very lethargic. This is two of numerous incidents.

I've talked to her a couple times about these things.. that breathing trumps med passes, the importance of assessing and investigating complaints, etc. But nothing's changed. I spoke to my DON about it, not because I want to tell on my coworkers, but I'm concerned about the safety of the residents in the building. She told me it was my word against hers (CNAs dont' count because they're not qualified to judge a nurse's job), and basically as long as she shows up for her shifts, gives her meds on time, and doesn't kill anyone they're not interested in pursuing it.

Every time I work with her, I get overwhelmed. I feel like I have to keep an eye on her, and care for her residents on top of my own and it's REALLY stressing me out and making me not want to go into work. I know this isn't an unusual issue in LTC... any tips on dealing with it?

[jadelpn, LPN, EMT-B]

Keep to your own self, and your own patients. You could report to the state, the omsbudsman, and/or elder services. Even to your parent company's corporate compliance line/risk management.

If your management is not interested in confronting this, there is little you can do in house to change it. However, you could have discussion with the DON about you being the "go to" for each shift you work. Meaning if anyone has an issue with a resident (regardless of whose patient it is) you are the "rapid response" person.

Get malpractice insurance. If there is a charge nuse in house for your shifts, and a CNA comes to you with an issue, go directly to charge. If there is no charge nurse, advocate for yourself to be charge, so that you can oversee and plan for the residents accordingly. I would broach it as "there are many times that residents have medical issues that need attention. There should be someone each shift who is responsible for overseeing the continuum of care."

Best wishes!

[Jory, MSN, APRN, CNM]

It's a bit interesting that it's always the CNA.

Only report what you directly observe, everything else is just hearsay. The CNA has the ability to report as well and I would remind her of that since she's the one that keeps witnessing these events. However, it seems she's content with sending you to tattle because she doesn't want to be associated with it.

[heron, ASN, RN]

Agree, report only direct observations. It could be someone's being set up. Proceed with caution and don't get sucked into a conflict that has nothing to do with you. The CNA is basically running behind your coworker's back and getting you to take care of residents not assigned to you. This could well be staff-splitting. Please dig a little deeper before riding off to the rescue.

[morte, LPN, LVN]

per the OP, she has already talked to the other nurse. next time it happens, perhaps getting the nurse to come with you, and asking her if the CNA has informed her of the issue.

[heron, ASN, RN]

@morte: that's a good idea. The info in the OP was necessarily limited and could fit a number of different scenarios.

We've all been in the quandary of trying to get a provider to address a situation before badness morphs into an unnecessary emergency.

I've also had an on-the-ball CNA ask me to check out a less than vigilant co-worker's resident. I know these situations happen.

I guess that there's something about appointing oneself supervisor that puts the hairs up on the back of my neck. Ditto with the suggestion that calling the OP to assess her co-worker's residents has become somewhat routine.

The OP's advocacy for her co-worker's residents was impressive and entirely appropriate. But assuming total responsibility for monitoring her co-worker's practice and the welfare of her residents seems to be a bridge too far.

Why not simply check out the specific report, do what is needed for the resident's safety, document that, then inform the co-worker and go about your business? (And, perhaps, suggest that the CNAs be trained to fill the O2 tanks.) Just make sure that the CNA's know to use you as a resource only for serious issues - not every bruise, skin tear or refusal of care.

[Here.I.Stand, BSN, RN]

Sheesh, hypoxia and new hemiparesis taking a backseat to the med pass? These people are supposed to be receiving nursing care...not get thrown pills by a trained chimp. I get med pass is a huge job in LTC, and shouldn't be interrupted for routine requests... but those are significant changes in condition, and time is brain.

I personally wouldn't be quick to discount a CNA's observation. They are not trained to assess, but they can see that something isn't right, especially when they spend SO much hands-on time with the residents. And anyway, you saw the empty O2 tank, SpO2 of 78%, slurred speech, hemiparesis, etc. Very different than a their-word-against-hers situation.

This is a tough spot for you to be in, but these vulnerable adults need an advocate, we are mandated reporters, and clearly the DON is more concerned about warm bodies than about these people. I really think you need to report this--just what you've observed, of course. It also isn't fair to you to feel like you have to monitor your own residents and hers. Besides, if she is incompetent, she is whether you're there to cover her rear or not.

[TheCommuter, BSN, RN]

Based on my six years in LTC at several nursing homes, some of the nurses in this industry specifically choose to work at nursing homes because they know they can fly under the radar and get away with rendering subpar care.

LTC is the only setting in nursing where a patient can stroke out and be ignored if the nurse on duty is more focused on getting her med pass done.

I do not mean to offend. I'm just relaying my observations. Most of the nurses in LTC are great, but the ones who fly by the seat of their pants give everyone in the nursing home industry a crappy reputation.

[Oswin]

Thanks for the responses, everyone. Let me clarify a few details that you've brought up.

If there is no charge nurse, advocate for yourself to be charge, so that you can oversee and plan for the residents accordingly.

Best wishes!

We alternate being charge nurse when I work with her, per the scheduler. There are only 2 nurses in the facility on 2nd shift, and the scheduler assigns charge nurse status.

This is actually part of my problem... I'm concerned this nurse is genuinely incompetent (and that's not something I say easily about a fellow nurse...), not just lazy. I believe she assessed a resident who was having a stroke and didn't notice the symptoms, and is unable to prioritize breathing issues over her med pass... it seems like in her brain, the med pass trumps anything other than chest pain, no matter how many times I try to gently nudge her toward ABCs. When that resident was satting at 78% I told her about it afterwards, since it was HER patient... and she actually replied "Well, thanks for taking care of it, but he would have been fine until I finished my med pass." (And yes, I did tell that to the DON, too.) I hate being charge over her because I know that ultimately the responsibility of her actions then fall onto me... and I don't trust her. I've only been a nurse for a couple years, I guess I've been fortunate not to have encountered this before, but I don't care for it!! lol.

It's a bit interesting that it's always the CNA.

Only report what you directly observe, everything else is just hearsay. The CNA has the ability to report as well and I would remind her of that since she's the one that keeps witnessing these events. However, it seems she's content with sending you to tattle because she doesn't want to be associated with it.

Sorry, I guess I didn't explain as well as I thought I did. It's completely natural for the CNAs to report issues they see to the nurses, it's part of their job, even. These are multiple CNAs over months who reported problems to the other nurse, and when the other nurse said she was too busy to address them, or ignored the issue, they brought it to me because they were worried about the resident. The CNAs have reported this to our DON, and I have reported my assessment results as well as my conversations with this other nurse to our DON....the bigger issue is that the DON doesn't care because she doesn't have staff to replace her. And I have no control over that, of course... as frustrating as it is.

The CNA is basically running behind your coworker's back and getting you to take care of residents not assigned to you. This could well be staff-splitting.

I don't think this is the issue in this case, though that's generally good advice. Also, I always ask them if they've reported the problem to that residents' nurse first, before I go see the patient (unless it's an emergency, of course). The CNAs may not be trained to assess, but they spend so much more time than we do with the patients one on one... they know when someone's not acting right.

Thanks for those that suggested bringing her with to assess the patient. I think I might start paging her to the patient's room when the CNAs bring something to me and it seems to be serious, and see how that goes.

[morte, LPN, LVN]

have you checked on line to make sure she has a license?

[Adele_Michal7, ASN, RN]

In addition to wanting to echo what other posters have said... Be careful you don't get sucked in too much into doing what other people should be doing. If a nurse is negligent, drowning, etc, you should and can report this and upper management or a shift sup should counsel/monitor her during work hours. I'm sure you have enough on your plate without having to take on more. If anything were to happen to one of your residents while you were helping her, upper management would probably hang you out to dry!

[phalanx]

When I was a newer nurse I did have issues with CNAs reporting things about my residents to other nurses "behind my back." One in particular refused to learn my name, she would call me any name in the book from down the hallway and if I did not respond to it she would immediately go to another nurse and tell them that she had "tried to tell her about it but she is ignoring me." A year into working with this person on a near-daily basis (my unit manager refused to move her because she was a 'good aide' despite residents complaining about her rudeness all the time) she still did not know my name, and she finally did it RIGHT IN FRONT OF ME (went up to another nurse and was whispering that "She just won't do anything" about something she had NOT told me about) and I told her that if it was too difficult to learn someone's name that you see every day and cannot read my name tag with inch high letters then I did not feel safe with her assigned to my unit.

I see it now as well as a treatment nurse - the CNAs will tell a nurse something, it may be an inopportune time and the nurse doesn't do it right away and they feel as if they are being blown off, or the nurse may go assess and feel that it's not an emergent issue, and if the CNA doesn't think what they did was "enough" or didn't fix the situation then they will go around telling everyone that the nurse would not do anything, and then they use this to justify not reporting future issues because "Why should I waste my time when she never does anything?"