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?

[kp2016]

On 6/16/2019 at 8:54 AM, TriciaJ said:

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

Exactly!!! I thinking there may be a significant amount of denial from the family about their loved ones health and life expectancy. I’m thinking blaming you for her “decline” is an outlet for their anger and grief. Understandable but really unfair to you.

If she had a stroke like event the ER would have done a CT scan and got a neuro consult, not sent her straight back to you. The “team” should focus on helping this family with the reality of her dementia diagnosis. Singling you out for blame for the patients decline is grossly unfair, and frankly the opposite of helpful given the larger picture.

[FolksBtrippin, BSN, RN]

She went to the ED. Did she get a diagnosis of an "event" or stroke, like the team lead thinks? It is ridiculous for your team lead to speculate on that. Find out what the ED says about what was going on with your patient.

I'm sorry you've been treated this way. It seems to me like you did the right thing. You called your RN sup who gave you good direction. When the pt did not improve, you called doc. This is exactly what you should have done IMO. If you really made a mistake, you should be educated by your manager exactly on what you should have done differently. Were you supposed to not take direction from your RN sup? I find that unreasonable.

The situation stinks of family upset, so berate the nurse. Stand up for yourself if necessary.

Eta: just read that the ED did not report a stroke. Your team lead is way out of line. I would consider another job.

[Forest2]

Something we learn as we go, "defensive nursing", especially true when a family has unrealistic expectations and a lack of understanding.

[KCMnurse, BSN, MSN, RN]

Please do not continue to beat yourself up about this. It is easy to come in and play Monday morning quarterback and play the blame game. They weren't there and based on what you wrote I would have probably completed the same actions you did. This blaming and shaming mentality has everyone second-guessing their actions. If the ER did not diagnose a stroke or similar event how the heck are they making that reach?

[jane_34]

Thank you all for the replies. Just to update you I am still working, didn’t lose my job. The resident is the same now as when she moved in. The team lead still thinks she had a stroke. They have stopped pointing fingers at me for now. I notice anytime something like this happens, everyone is so quick to throw someone under the bus, even if it’s just for insignificant/trivial things. Not sure if it’s like this everywhere or just the culture of my workplace.

[JKL33]

7 minutes ago, jane_34 said:

The resident is the same now as when she moved in. The team lead still thinks she had a stroke.

Out of curiosity, is she still on the medication (or similar) that was coincidentally initiated during the same period as her "decline"?

Well, anyway. Realize that some people have a small knowledge base which affects their capability for assessing situations and coming up with ddx. It makes them feel good to declare what they think they know, and especially to claim that someone else doesn't know what they know. Nevermind all of that.

If it's more than just a random know-nothing spouting off, though, and this is a regular occurrence where there is serious finger-pointing for every little thing, I would get out of there.

[canoehead, BSN, RN]

Maybe she did have a stroke, but she also had a good reason to be sleepy that morning. You did what I would have done, and hindsight is 20/20.

[jane_34]

Thanks to all for the replies. I really like seeing things from different perspectives. They discontinued that medication pretty quickly after the incident happened. Everything seems to have settled down at the present time and it's in the past for the most part. But whenever family members of this resident come to visit, they still give me the stink eye. It hurts, but not much I can do about it now.

[JKL33]

9 minutes ago, jane_34 said:

But whenever family members of this resident come to visit, they still give me the stink eye. It hurts, but not much I can do about it now.

That part of it is somewhat understandable. Families are generally not experts on a health crisis such as early-onset dementia. And the grief along with the practical stressors can be overwhelming; sometimes harboring feelings of (inappropriate) blame related to the situation is a defense mechanism. It is not healthy coping; it is a defense mechanism against inner turmoil related to the situation.

None of that grieving process is helped by a speculator and Monday-morning quarterback who, in theory, should know better--such as your team lead. It's hard to expect that families will remain perfectly objective and level-headed when there are saboteurs of questionable intelligence running around talking nonsense.

Treat this family with basic kindness and perform your duties to the best of your abilities; don't comport yourself as if you have done something wrong. They will either come around or they won't.

Take care~

[Forest2]

On 6/29/2019 at 11:01 PM, jane_34 said:

The resident is the same now as when she moved in. The team lead still thinks she had a stroke.

If there are no signs, face, arm and speech, and the CT is negative, then she is wrong.