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?
Are you sure she understands what happened. Sounds like she needs some education about what "out of time range" means. Many nurses do not understand that QD means you can give it once per day. They do not understand that times on MARs are nursing judgement. Now of course if the MD ordered Lantus to be giving at 0600, then she would have been within her right to refuse to give it without contacting the dr. But she should communicate that to you.
Not much else you can do besides writing her up and keeping an eye on her.
Just wondering, why did the night nurse not get written up also? Or am I confused.
The night nurse had med errors. They were reported. The day nurse was just - defiant. That's the write up. Med error reports are for seeing what went wrong in the process and improving performance, not punitive. And really, I would NOT have written them at all if day nurse wasn't just such a witch. We would have given the meds late with the administration times captured in the audit trail and gone on because none of it was crucial.
She understands all of it. She told my floor charge once that I am not going to "tell her what to do."
The night nurse had med errors. They were reported. The day nurse was just - defiant. That's the write up. Med error reports are for seeing what went wrong in the process and improving performance, not punitive. And really, I would NOT have written them at all if day nurse wasn't just such a witch. We would have given the meds late with the administration times captured in the audit trail and gone on because none of it was crucial.
She understands all of it. She told my floor charge once that I am not going to "tell her what to do."
I have seen (and worked with) these kind of nurses. Cover you butt and continue to write her up. At some point it will catch up with her. Sorry you have to deal with this.
Sue, I just wanted to tell you what I would have done , instead of what she did. I would have given the meds as you asked me to. But I also would have made a notation on the back of each patients MAR page and stated, Med given @ such and such time, as per Sue RN nurse manager. I would have been covered, you would have been happy, and most of all the patients would have gotten their QD meds. Not sure what all of the meds were, but I would have made sure if they were TID or QID, that I made sure that the next dose was not given on time, and again, when the med was given, I would have made a note on the back of the MAR, why. Also this information would have been passed along in report to the next med nurse. Some people just don't think. Hold your head up high, you did the right thing.
The night nurse had med errors. They were reported. The day nurse was just - defiant. That's the write up. Med error reports are for seeing what went wrong in the process and improving performance, not punitive. And really, I would NOT have written them at all if day nurse wasn't just such a witch. We would have given the meds late with the administration times captured in the audit trail and gone on because none of it was crucial.
She understands all of it. She told my floor charge once that I am not going to "tell her what to do."
Yes, more of a case of her not doing what you told her to do, than a conscious decision on her part to withhold medication from the patients. Just because she thinks nobody can tell her to do anything, including the DON, is no reason for the patients to miss out on meds or other care. This person needs documentation on a path out the door, not to return. They can hand her the final pay check on her way out. This should be her future. We all know there is a nurse out there who will be happy to take direction from the DON or manager and see that the patients receive their care. Good luck dealing with this person and seeing that she goes away. Doubt she will ever decide to shape up.
The meds were vitamins, Prilosec, and Synthroid. Yup. And a glipizide and, oh yeah, 36 units of Lantus. The ONLY one more than once a day was the Lantus and a protein supp for skin integrity.
She really made a big deal out of nothing and it will bite her in the butt.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
The hardest part of being charge is this type of stuff.
That's right at the top of my "CON" column in the "pros and cons" of finishing the LVN-RN bridge. I'm still normo-tensive at 53. Not sure I want to mess with that. :)
Sorry you had the shift from the depths of hades, Suesquatch,RN. I would never have handled that the way she did even if I had an issue with it. She must feel awfully secure in her employment status if she isn't worried about that kind of defiance causing major repercussions. Maybe the several write-ups will get her attention. Hope so!!
Specializes in Peds/outpatient FP,derm,allergy/private duty.
What would you have done?
I would have given the meds when you asked me the first time. Insulin first.
If I ignored you twice even after you called the doctor, I would have expected to have my @ss handed to me right then and there. If I then observed you doing that thing that I had twice refused to do, and asked a snippy question about it, I would have expected you to march my little behind to whoever was higher up the chain. No? Does that sound too harsh? I don't think so if you consider the havoc she played on everyone!!
If I didn't feel right about giving something, I would ask you politely where I am going wrong and what you thought. Nobody who feels genuinely that an order is in error should give it by rote, but she was not interested in a collaborative approach!! I've been lucky to have awesome Nurse Managers over the years. I always think of them when I imagine situations like this!
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?
This is the difference between an RN with critical thinking skills, and an LPN who just "does' or doesn't," without any thought as to what the ramifications are. I cringe when I hear about hospitals who continue to allow LPNs work in the ICU, or ER. JMHO and my NY $0.02.
MERRYWIDOW46
311 Posts
I agree also. Suspension without pay at minimum.