Error in judgement?

[jane_34]

This is long, so bare with me. I'm an LPN in long term care. We had a new admission of a resident with severe early onset dementia (with high anxiety) a few weeks ago. She was prescribed too high of a dose of clonazepam by her doctor and got snowed the first time it was given. When I came in the next morning, she was sleeping deeply and would not rouse. The night nurse reported she seemed snowed on the medication and to watch her closely. She was breathing and did not look in distress. I thought she would just sleep in late due to the medication. I kept monitoring her, checked her vitals which were stable. Myself and the RCA assisted her to the bathroom twice over the morning and early afternoon. She could shuffle her feet, but was still heavily sedated. After lunch she still wasn't waking up, so I called the RN supervisor for advice. He said to hold her other medications unless she perks up, which were also anti anxiety meds. I continued to monitor, it was 14:00 and her status was not changing. I was concerned she was getting dehydrated. I called her doctor's office, but the doctor was away, so I spoke to a locum who recommended transfer to the ER, just to be safe. So I sent her in. In the ER, they gave her IV fluids and let her continue to sleep it off. They had nothing else to report upon her return to the facility. My manager and also the team lead LPN were both on vacation when this occurred. Fast forward to when they returned, they are asking me why I waited so long to send her to the ER. They said I should have sent her right away. The team lead thinks she had an event or a stroke, not a reaction to the med, which I should have been on top of and got her medical attention faster. This team lead thinks she is leaning to her left side, but I don't see it. She seemed her usual self. The family of this resident is also unhappy about this. They say they notice a decline in the resident and blame it on my error in judgement. I feel terrible and depressed about it. I am worried about losing my job. What is your take on this situation and how do you think I could have handled it better?

[GSDlvrRN, MSN]

Drowsiness could be an “expected” reaction. But what you describe is not. It is very important to know the difference. If you are unsure, ask the charge nurse/ supervisor to help assess the patient. Yes, she was sleeping which is expected, but you also said she was not able to be aroused. This is not an expected reaction.

Did she open her eyes on her own (spontaneously)? Did you call her name (arousable to voice)? Did you sternal rub (responding to pain)? This is part of a Glasgow Coma Scale assessment and I use it for a brief neuro assessment. As an LPN, you have the knowledge to determine if your patient is arousable. If they are not and this is a change from baseline, this is an emergency. You can immediately assess vital signs and blood sugar. ( By the way I started as an RN in LTC. High five sista!) I would go a step further to get a supervisor in the room, and call the doctor. Sometimes I wanted to send someone out and the DON always had my back if the doctor said no and the situation is serious enough.( I learned this stuff over time and got better at making quick judgement calls over time).

I personally wake up my patients completely when I get bedside report and introduce myself in the morning and ask their name, at the very least. That is a neurological assessment right there. (Forgive me if I use inappropriate terms for LPN scope of practice. I have been told LPNs cannot techniquely “assess” patients, in those terms, but they can “note” things like decreased respirations).

Here are a few things:

1. Not treating an emergent situation just the patient is still breathing. We need to intervene before they stop breathing. ( but consider their code status, of course) This is not an independent indication of whether or not the patient needs medical attention.

2.Getting caught up in numbers such as normal vital signs. ( don’t just treat the numbers, treat the patient). This is not an independent indicator of whether or not the patient needs medical attention.

3. Throwing around the term “vital signs stable”. (This term does not mean they are normal, it just means that they are not changing).This is not an independent indication of whether or not the patient needs medical attention.

4. Noting that the patient did not look in distress. This is also not an independent indication that the patient does or does not need medical attention.

I think you knew something was wrong, so you tried to utilize your resources. I think you noted certain important things like vital signs are stable and patient not in distress. I think you did all the right things such as calling the RN supervisor and locum, but remember prioritizing. Those things can be done sooner.

This situation will teach you OP, it is a lesson in judgement and decision making. And if your leadership cannot allow you to learn from this and give you opportunity to work past it, then they don’t support your personal advancement.

I do not feel it is right for them to place blame on you that you don’t deserve. It is way too far to say that the patient’s decline is your fault. Yes, the patient could have had a stroke completely unrelated to the medication given, or your care of the patient. It is never their responsibility to place blame, but they should, in better terms, identify the event as a system or process problem. There were many things that contributed starting with the MD prescribing the dose of anxiety medication, the RN who gave it, and including the RN supervisor who’s only advice was to continue to hold medications. You did not fail, there was a problem with the process. Remember that!

[jane_34]

Thank you so much from your input. I definitely learned from this, and will know what to do differently next time. I just hope I don't lose my job.

[GSDlvrRN, MSN]

1 hour ago, jane_34 said:

Thank you so much from your input. I definitely learned from this, and will know what to do differently next time. I just hope I don't lose my job.

No problem. You seem to receive input very well... a very good indicator that you can get past this! Best of luck.

[JKL33]

Agree w/ @GSDlvrRN. At the same time, people absolutely can be inordinately snowed in this scenario. I'm not convinced and I hate the fact that people's concerns (which very often have at least some degree of ignorance involved) can sort of become reality. It can be difficult to arouse some people who are merely sleeping soundly. I also have not helped too many people shuffle to the bathroom who were in the middle of experiencing unresponsiveness d/t CVA.

A patient presenting to the facility with this background/dx who receives a huge influx of new long-acting medication that is known for its ability to produce some degree of the exact effects witnessed, can have this reaction. I'm neither dismissive nor careless in my assessments, but I do like to at least consider common sense.

The half-life of clonazepam is 30++ hours.

The family notices a decline?? The lady is drugged up now and wasn't before.

***

Finally, yes. Send these people out, because. To make sure bases are covered in the patient's best interests, and to save yourself from "this." She would have arrived at the ED, received her head CT, maybe a few other basic investigations to make sure nothing else seemed amiss, maybe some fluids, still been snowed, they would decide whether or not to give her flumazenil (likely not). And they would send her back.

[Forest2]

Personally I don't see that you did anything wrong. The RN supervisor should have breezed through and checked in on her, then made a decision. If you need to tell them that is what you want them to do, then so be it. You could then chart that you asked for the RN SV to come and assess the patient and decide on a course of action. When things like this happen you have to spread the responsibility out else it all lands on you and we know how things go when that happens, The nurse that first noticed she was oversedated also had some responsibililty in this as well, and again the doctor too. It wasn't just you, it was everyone.

[canoehead, BSN, RN]

I would have done as you did, OP. I think they are being a little high and mighty with their hindsight.

[GSDlvrRN, MSN]

How is everything going now?

[jane_34]

Things seem to be ok. I haven’t heard anything more about the incident. I’m hoping all is well. Thank you so much for all of your input, it was very helpful and good to have a different take on it.

[sweetiepeas]

Did anyone question the high dosage?

Did any one call the doctor to report her response?

Those would be my first questions.

You sought help but trust your instincts. You knew something wasn't right. Have a little faith in your judgment. Take this as a learning experience. Not something I'd fire you for.

[TriciaJ, RN]

Woulda-coulda-shoulda. Nice of 2 people to breeze back in and second-guess you. I'm betting if you had a lower threshhold to send people out you would have been second-guessed for that.

I'm with JKL: if someone can be groggily shuffled to the bathroom they aren't exactly unresponsive. When she was sent to the ED it was up to them to diagnose whatever was going on. The administered fluids and sent her back? So be it. Sounds like you were on top of things the whole time.

Use this as a reason to lower your threshhold to send people out. Your admin (or whomever) can gripe about the cost but you can save yourself a lot of stress by erring on the side of safety.

Sounds like the lady is as fine as she was ever going to be.

[Glycerine82, LPN]

What does the d/c summary say?