Devastated over Isolation Precautions Problem

[Ioreth, ADN, RN]

I just finished one of those night shifts where I ran the entire shift and did not sit down until after giving report. One of my patients was CIWA and required hourly scores/rechecks and was becoming increasingly difficult to manage. My other patients were OK for the most part, but busy. At 3:30 AM, we got a transfer from another floor on contact precautions due to MRSA.

Immediately after taking report by phone, I told my charge that the patient needed an iso cart. In our hospital in pre-covid days, we could just go to the basement and grab one from where they were stored. This was no longer the case, and the iso carts were locked up. I did not know the procedure for getting a cart, because needing to get a cart on nights on this particular floor is rare. I don't think I was ever told the procedure in any meeting or email, but generally charge will call house supervisor and they will bring in a cart. Charge called house sup right away, but there wasn't a cart brought before the patient arrived. There was another iso patient two doors down, so I made sure everyone on the floor was aware and we used that cart for both patients.

Here's my mistake: I didn't get signage on the new patient's door. Call it running my tail off. Call it inexperience. Call it dead tired. Call it sheer stupidity. That is my fault and my mistake. Yes, this should have been done the second the patient arrived and I messed up.

At 6:30, I realized that we still didin't have an iso cart for that patient. I told my charge and she called house sup again. Cart hadn't arrived by shift change. I butted into to huddle to speak up about the issue so that everyone would know. Oncoming charge said she already knew and was on it. Day CNA was late to work, but I made sure she knew too. 

I was finishing up charting when the assistant manager over our unit and another unit came by and asked if there were any safety issues. I immediately told her about the difficulty getting an iso cart. She asked if there was a sign on the door, and I told her that I had not put a sign on the door. She tracked down a cart in short order and got signage up.

What happened next has me questioning everything about being a nurse. At the nurse's station, in front of anyone who might have been there, my assistant manager (I'll abbreviate AM) asked me what the breakdown was in getting a cart, and I started telling how we started trying to get one when I took report and I was having difficulty with my CIWA patient during that time. She didn't let me continue. She told me that it took her two minutes to get a cart and there no excuse for not having one. She said it was solely my responsibility, not charge, or anyone else.

My charge was about to leave and walking by. She reiterated that we had tried to get a cart. The AM then told us a process that I have never before heard involving going to a different place and using a door code to get an iso cart. Charge had also never heard this. 

The AM is not wrong. I screwed up by not having a door sign, even if was photocopied from the other cart. I left that day feeling humiliated and wondering if I should just get out of nursing. I work tonight and I don't see how I'm going to sleep. I don't know what I'm asking by posting this, just please don't eat me alive. I'm already doing that.

[Ioreth, ADN, RN]

Something else that is bothering me about this situation is that she said "this is the second time you've had this problem." I wracked my mind but the only thing I could think of was one of the very rare times we had a Covid rule out on this floor. This patient also had an iso cart problem, but we used a chair to hold gowns and gloves until we got one a few hours later. In that case I had photocopied a sign from another iso room, but later I was told by an irrate lab worker that the sign was wrong because it was not purple. Heck, this was the first time I'd seen a Covid rule out on this floor and I didn't know we had purple signs, and there weren't any in the other cart. (Previous to this we had a Covid cohorted floor, but that had been discontinued.) I had done as we always did and followed the isolation markup in the chart and put up matching signage. My charge (a different person than the previous post) was involved the entire time and she hadn't known of any purple signs. 

I just looked back through my work email, and we've never gotten anything that I can refer back to regarding signage or changes in procedures in getting iso carts.

[Nunya, BSN]

Quite frankly I wouldn't worry about it.  Everyone who needed to know the patient was on isolation knew, and those of us who work nights know that what's easy to do during the day isn't always easy to do at night.  You made a mistake but it didn't harm anyone.  You're not perfect.  Things get away from us sometimes.  It should like you did everything right, sup and charge knew and if the charge didn't know something then it's not your fault.  If you want to say something so it won't come back to bite you at evaluation time then write down what happened and have your charge sign it too.  It'll be OK.  Once again, no one was harmed.  Don't let one mistake make you rethink your whole career. <HUGS>

Edit: it wouldn't hurt to keep one or two iso signs in your locker for the next time this happens, at least you won't get lab mad at you for not having a purple sign.  But she could have read it...I read every sign on a door since I figure it's something important....snark

[Ioreth, ADN, RN]

Thank you, Nunya. I appreciate your response more than you can know.

I need to get some sleep, but I'm just sitting here scrolling through AllNurses and running my brain in circles. This has been a rough first year as a nurse an a rough year with Covid and I've come to realize that my unit isn't doing that well. (I've posted a bit on this lately, all in my post history.)

I know I'm a good nurse. I won't say I don't make mistakes; we all do. I'm really, really good at catching out of control pain and titrating back on meds once the pain is "caught". If something is new, then I tend to question it until I understand it, and many times this has brought better understanding of whatever thing to the entire unit. Recently I realized our unit was doing CIWA incorrectly and wouldn't let go until we were in line with policy and current research. I've been called the "grumpy old man whisperer" because I can calm almost any angry patient by taking them seriously with their complaints and helping them align their personal goals/needs with their medical goals/needs. I roll well with getting the truly weird stuff late in the night (rattlesnake bite after fall inside home, ATV accident leading to crushed testicles but no other injuries, and spinal injury doing some impressive parkour with video). I've also caught dozens of near misses in orders and patient care that would have resulted in patient harm or death if unaddressed.

I just never hear any positive feedback from my manager or other leadership. It's always either "good job unit" or "you personally screwed up". I'm the type that tends to internalize the screwups and dismiss the "good job unit" since they're shared, not individual kudos. 

I'm most upset that this was all on me and all very public. There were so many other hands involved, but none of that matters. I get that it is the primary RN's responsibility and I dropped the ball, but I feel so alone in that there are no other considerations.

[Sour Lemon]

"I had no idea. Thank you, I'll do that next time."

There's no point in trying to reason with someone like that. They don't want to understand, and you'll only frustrate yourself by trying to explain. Just tolerate it until you get irritated enough to move on to the next job.

[amoLucia]

OP - you didn't screw up. In fact, I was rather impressed that you were able to try to cover as well as you did. We night-shifters, become masters at 'making do' and 'improvising'. It's like we're the 'forgotten stepchild'. Until the stepmother and stepsisters want something from Cinderella!!

And you're right - seldom is there any positive feedback, only the negative. And then it WAS uncalled for for the AM to publically snit at you. Who knows, maybe she had issues from the other unit that was peeing her off, and you just happened to be the punching bag. Her BAD!

I don't think much will come about this. Keep some notes for yourself re the situation. And get some sleep - you did fine!

[JKL33]

3 hours ago, Ioreth said:

I screwed up by not having a door sign, even if was photocopied from the other cart.

You need to stop with this self-deprecation. If you make a big mistake you can admit it. If you don't have time to fix every one of administration's meddling mishaps, you don't need to take responsibility for that, and it actually weakens your position when you do so. The treatment you invite is often the treatment you will get.

In general, talk less, avoid being defensive.

"We called for a cart twice and I didn't have time to do more than that."

THE END.

Go to sleep. Let it go. When you wake up, buck up. ???

[NightNerd, MSN, RN]

Sounds like a huge overreaction on your AM's part. You made sure everyone who needed to know, knew, and enlisted help trying to get the cart. You did the best you could under the circumstances, and it sounds like the combination of the usual night shift struggles and all the new procedures with COVID made it unclear what you were supposed to do in this situation. It's super annoying that she was so crabby with you, but honestly, I can't think of much else you could have done. Hope you're able to get some sleep and that the next shift is better! You did just fine.

[MunoRN, RN]

You did everything that could have been reasonably expected of any nurse, there's no reason to feel as though you failed.  The only thing I might have done differently is that ideally each isolation cart has spare signs in it, there may have been a sign in a different cart on the floor.

If there's any 'fault' here it's pretty clearly with the AM and the rest of your unit management since there was a practice change which wasn't effectively communicated.  You handled it very diplomatically, I would have been more direct about where the failures that led to difficulty obtaining an isolation originated, and those failures clearly didn't come from the direct-care staff.

[amoLucia]

NightNerd - Is that Dr Nowzardin's picture with your name?

[NightNerd, MSN, RN]

39 minutes ago, amoLucia said:

NightNerd - Is that Dr Nowzardin's picture with your name?

It's a meme but it's admittedly pretty hard to read the text. His commentary on that show used to crack me up.

[Been there,done that, ASN, RN]

You did a great job. You and the charge nurse tried several times to get the isolation cart. AM needs to come down on the supervisor on duty, for not providing the cart.. not the staff running around to provide care. THe AM IS wrong and a bully. Don't beat yourself up over this. 
You could get some brownie points if you request extra signage available for all situations. That should be available anyway.