Defiant and Insubordinate

[SuesquatchRN]

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?

[SuesquatchRN, 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.

This is an excellent suggestion. Thank you!

[mc3, ASN, RN]

I hope I don't get jumped on for this, because I would not have handled in the same way that she did, BUT...........If the insulin was not given in the correct time frame, it then becomes a med error, right? Then, you correct it by contacting the MD and letting him/her decide what to do next, which in this case was to go ahead and give it anyway, even though it was late. It sounds like you told her to give it anyway, then contacted the MD. That part of it is what I don't see what she did was wrong. Maybe she thought it would be be wrong because she made a med error and didn't have a doctor's order right then and there to go ahead and give it anyway. In her mind, just because an RN told her what to do, if she believed it was wrong she didn't do it, ie. if an RN told me to give double the dose of something and I didn't have an MD order I wouldn't, even if you (the RN) told me to. In any event, she should have discussed it with you right when it happened, though, not just ignored you.

mc3:nurse:

[caliotter3]

If I had a conflict with what my supervisor told me to do, I would discuss it with that person right then and there and it would be resolved. To just go behind your back and countermand your instructions is, of course, passive aggressive and insubordinate. You need to keep on the write up course of action and discuss this with the DON. This nurse is going to get other nurses in trouble some day if she keeps this behavior up, not to mention the poor patient suffering because of her poor judgement. In few instances have I ever seen that a missed med be skipped rather than given late, all with appropriate documentation. I suppose she did not write a word about why she was skipping the doses. Was just going to pass everything off on the next nurse. She bears watching and watching closely.

[Valerie Salva, 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.....

ITA!

This floater's nursing judgment, common sense, critical thinking, ability to follow directions, and brains seem to have floated away.

What an idiot.

[SuesquatchRN, BSN, RN]

Meds can be given late. This is not a hospital, they were all QD meds, and our policy is NOT to call a physician at 7 am on a Saturday to find out if the synthroid should be given because it's late. You give it and document. Certainly any time-sensitive meds would have been handled differently.

Besides, she managed to not give them even AFTER the doctor said to give them. This is defiance. And she has done this to me before, once in front of the DON, who told her to give the meds even if they were late.

I don't want her to be an automaton, and I have LPNs to whom I will gladly defer in a heartbeat. I am collaborative, not an autocrat. She is not one of them as she shows such a glaring lack of clinical common sense.

[Mulan]

Had the night nurse already clocked out? If not, why not have her give them before she left.

[caliotter3]

When she refuses to follow instructions given by the DON, something is definitely wrong with her. I would make an effort to assist the DON to see that she needs a different place to work. She is just short of dangerous.

[SuesquatchRN, BSN, RN]

Had the night nurse already clocked out? If not, why not have her give them before she left.

Because she was passing meds on the sub-acute wing already. And frankly, it didn't occur to me. I thought that my floor nurse had followed instructions and given them.

[mc3, ASN, RN]

Meds can be given late. This is not a hospital, they were all QD meds, and our policy is NOT to call a physician at 7 am on a Saturday to find out if the synthroid should be given because it's late. You give it and document. Certainly any time-sensitive meds would have been handled differently.

Besides, she managed to not give them even AFTER the doctor said to give them. This is defiance. And she has done this to me before, once in front of the DON, who told her to give the meds even if they were late.

I don't want her to be an automaton, and I have LPNs to whom I will gladly defer in a heartbeat. I am collaborative, not an autocrat. She is not one of them as she shows such a glaring lack of clinical common sense.

Gotcha! And I'd come work for you anytime, Sue!:D:D:D:D

mc3:nurse:

[Valerie Salva, BSN, RN]

The hardest part of being charge is this type of stuff.

[SuesquatchRN, BSN, RN]

Gotcha! And I'd come work for you anytime, Sue!:D:D:D:D

mc3:nurse:

Thanks. Hey, I have been known to defer to the aides. If I say, "Let's try so-and-so with Mrs. A" and they say, "Oh, that's not a good idea because...." you can bet your sweet bippy I believe them. They're the ones getting pinched and smacked by the demented ones, not me. Bless them.

And every resident who has been sent out since I STARTED here has been sent because a smart, astute, caring CNA picked up the change in status.

[Valerie Salva, BSN, RN]

Thanks. Hey, I have been known to defer to the aides. If I say, "Let's try so-and-so with Mrs. A" and they say, "Oh, that's not a good idea because...." you can bet your sweet bippy I believe them. They're the ones getting pinched and smacked by the demented ones, not me. Bless them.

And every resident who has been sent out since I STARTED here has been sent because a smart, astute, caring CNA picked up the change in status.

Reminds me of a CNA who saved a pt's life years ago.

I was working agency on a LTC unit- I had never worked there before and did not know the residents at all. This was a noc shift.

A CNA approached me after first (2400) rounds and said "Mr. X usually hits me and gets upset when I change his brief, but he just laid there like a lump this time."

I checked Mr. X's MAR and saw he was a diabetic. I did a fingerstick and his BS was 35. I was an LPN at the time, so I put in a STAT call to the RN who was in another building to come start an IV and push D50- NOW, and I put glucose gel under the pt's tongue. The RN rushed over pushed D50, and the unconscious Mr. X woke right up and was fine.

This pt's routine FS was not due until 0600- a full six hours later. If the CNA had not told me that the pt's behavior was different, he would have surely died.

I wrote a glowing letter to the CNA's DON, and later went to work at the facility as a regular employee.

Great CNAs are as rare as diamonds and are far more valuable.