Defiant and Insubordinate

[SuesquatchRN, BSN, RN]

I am an RN. I manage a unit and LPNs do the floor work. They are subordinate to me, in licensure and hierarchy. I do NOT play that up.

This morning, a "floating" nurse had the 6 a.m. medication pass and missed meds for 4 patients. Most were not critical, one was a huge dose of insulin for a diabetic whose blood sugar has been out of control.

The LPN notices the meds were missed. They are now 1 1/2 hours out of range for compliance with being given at the right time. The night nurse was still in the building so I verified with her that she had NOT given the meds. I told the current nurse to give them. She said nothing.

At 1130 she tells me that the patient who gets the insulin has a blood sugar of 463. I asked, "Even after the 36 units of Lantus?" She says, "I didn't give any Lantus. It was out of the time range." "Did you give everyone else their meds?" "No, I can't. They're late." Now, "nursing judgment" is the prerogative of every nurse, but the supervising RN supersedes the LPN. I've been an LPN and know how frustrating that is, but LPNs work under the direct supervision of RNs. And I am responsible for what happens when I am the supervising RN.

At this point I have to call the doctor AND write up the night nurse for med errors. What should have been simple is now a big hairy time-consuming deal. Of course, he tells me to give all the meds as none are that time-sensitive and need to be given.

I note all the charts and tell her to give the meds.

And I write her up.

All hell breaks loose. Even the aides are yelling about how unfair it is that A made an error and B is getting written up. I leave the unit for 20 minutes to compose myself. Meanwhile, I have a resident running two separate IV antibiotics and have administrative tasks to perform and am now behind because I spent an hour writing up errors, calling doctors, and writing up people. None of which whould have been necessary had she not just been defiant.

2 pm comes and I notice that she hasn't given the meds. I start passing them. She actually says, "Are you giving those 5 am meds?" "Yes." "You need to write orders for them all." "Um, no, the system will mark them at the time they were given." "Yeah, but no one will know they were late unless you write a note." "You think I didn't write progress notes two hours ago when I gave you the instructions to give them?"

WTH?! HOLDING 36 UNITS OF INSULIN? THAT'S NURSING JUDGMENT BY HER? And holding glyburide on someone else, who gets only that all day for her BS?

What do I do with this brat?

[ellakate]

Sue,

Since she is a floater, ask your supervisor if this is a trend, or if this has been reported before.

Then go gaily forward!!

[mamamerlee, LPN]

You did the right thing. Now you need a neutral place to explain why she needed to give all those meds, and who is in charge.

BTW - the Lantus wouldn't have made that much of a dent in that high of a blood sugar, and Lantus should be given in the evening, anyway.

[SuesquatchRN, BSN, RN]

I know that about Lantus, but she has been so unstable that the doc has been trying everything. It wasn't so much that the Lantus would have made such a dent but to withhold such a huge dose of a crucial med because it was late? This is LTC. We're not titrating Cardizem drips!

[MERRYWIDOW46]

Actually, our endocrine doctors are now giving Lantus Q12H, especially in those who run high blood sugars throughout the day.

[TwilightRNurse]

Nursing judgement is not necessarily a solo act. She should have conferred with you that she wasn't giving them and why. I would have been livid. Those who don't agree with you don't have a leg to stand on. You're in charge, it's your license and they're opinions don't matter. Let the write up stand and speak to the DON.

[MERRYWIDOW46]

I would ask others if this behavior is common for the floater, if it is I'd write her ass up from here to the moon and back. That is just inconscionable to NOT give meds that are QD and for diabetics becasue they are "LATE". Especially after you spoke with the physician and he wanted them given.

ALSO, why didn't the night nurse give the meds as ordered????????? Is this a common occurrance for her to not give meds????????

Good Luck.

[pennyaline]

Too right, girl, too right! If the second nurse did not correct the other nurse's error when she was instructed to, she deserved to be written up. And when she decided arbitrarily not to give overdue meds, she deserved a second write up. It's a PIA, but the prescriber should have been notified as the only one who can decide not to give overdue meds is the prescriber. Then, when she went out of her way to quote policy and procedure for writing orders for late meds, she deserved a third write up for knowingly violating facility procedure.

Some of these nurses these day, I'm telling ya!

[morte, LPN, LVN]

so, if i am reading this correctly....she passive aggressively did not give these meds, not once but twice.?

she needs a suspension, not just a write up.....

[SuesquatchRN, BSN, RN]

so, if i am reading this correctly....she passive aggressively did not give these meds, not once but twice.?

she needs a suspension, not just a write up.....

Yup. And I agree.

[SuesquatchRN, BSN, RN]

ALSO, why didn't the night nurse give the meds as ordered????????? Is this a common occurrance for her to not give meds????????

Good Luck.

We're on a computerized system (beautiful!) and she did not know what our med pass actually begins at 5 am. When she got into the system they had already cycled off into "overdue" and she didn't catch it. She WAS in error, but it was understandable and not insuperable. There are 44 residents and she hasn't been on this wing in quite awhile.

[katkonk, BSN, RN]

Don't know how large your institution is, or if they have a process for recommending an employee go through some remedial education as far as policy and procedure, but if you do, it might be a good idea. Sounds like she is so focused on the details of if a med is given late, and documentation, that she is missing the entire goal of care. At some point she needs to be reminded that the goal of care is a clinical goal of keeping the patient healthy....and, uh...oh yeah...ALIVE as well! i.e. someone who gets glyburide q.d. needs it...whether it is late or not. The Lantus would be unlikely to bottom anyone out, especially with a blood sugar reading that high. But mostly, she needs to have it documented in her personnel file that she was (or will be) counseled on the process for bringing concerns about medicating someone late to her supervision in a TIMELY manner, so that the patient doesn't suffer adverse consequences. She is not free to ignore orders to give meds at her discretion.