Ethical advice needed for a new grad...

[AnnaleaRN]

What would YOU do?

Say, hypothetically, that you are a new graduate RN at your first job. During morning med pass at a SNF, you witness another RN entering incorrect times for med administration on multiple patients in order to seem like everyone received their medication within the designated time frame. When you asked this nurse about the times, she states that she "guesses every nurse has to make a judgement call on how to chart."

Would you take it further? Would you ignore it?

[joanna73, BSN, RN]

Working LTC, we think of it as home and providing comfort care mostly. That does not mean that there isn't a standard of care, but many meds are BID, TID or QID so the window of time can be more flexible.

Medications such as insulin, digoxin and certain antibiotics that need to be taken with food should be scheduled. Am i concerned about giving a tylenol later, calcium or colace? Not likely. You will learn to prioritize certain things and not worry so much about other less important tasks.

Since you are a new grad, you may want to focus on your learning needs and finding a routine that works for you rather than a coworker's practise.

[Debilpn23]

As a DON in a 68 bed facility-I feel the generalization of Nursing Home staffing offensive. I have been here 20 years. We continue to be a 5 star facility, and our staffing is ABOVE the industry norm. We have 28 Nurses, 24 of them RNs. We have had surrounding facilities tell us we "over staff" and make it bad for the rest of them. I AM management. I set the staffing. We have 4 nurses on days and evening shift. We have concentrated on DECREASING the number of medications our residents receive, because polypharmacy is the actual issue, not staffing. If I am 97 years old, DO NOT put me on a cholesterol medication, multiple blood pressure medications, antidepressants and multiple vitamins. Please do not color all Nursing Homes with the same pen, we are not the same.

LCPHrn

I would love to work at your facility.

[Spidey's mom, ADN, BSN, RN]

I understand leeway in taking certain meds - but it has to be part of the plan of care or policies and procedures or standard of care or whatever you want to call the rules. So, yes we are allowed, as an example, 30 minutes prior to and 30 minutes after scheduled time to give the med.

Seems like there are two issues here. Do we lie and chart we gave a med at a certain time when we did not? And does it hurt a patient to get their Colace or Tylenol or calcium early or late?

As a hospice nurse I've seen patients mess their bowel protocol up by not following the time limits for stool softeners and/or laxatives. One man just OD's himself and ends up with days of diarrhea. The way we give meds to keep a person's bowel movements . . . . moving on a regular basis does depend on consistency. It is very important for our hospice patients, many of whom are on a Dilaudid or Morphine CADD Pump with the lovely side effect of constipation, to stay precisely on a good bowel protocol. Otherwise you might be dealing with loose stool for days or SSE time. And our patients are not thrilled with SSE's.

Giving Tylenol early can have a negative outcome if this is done on a consistent basis as you can have negative consequences from too much acetaminophen in 24 hours.

Calcium usually needs to be given with food in my experience so yes, there is a time and place for that med as well.

All meds have side effects. It isn't good nursing to say it is just a stool softener or a Tylenol so it shouldn't matter when we give it.

[LCPHrn]

We have 7 Nursing Assistants, 3 Restorative NACs, 2 Bathaids on Dayshift + 1-2 paid feeding assistants for NAC support. Evenings we have 6 NACs, 1-2 feeding assistants.

[hope3456, ASN, RN]

LCP do you have better funding than other facilities? How did you manage to pull it off?

[docomo]

if you are a new grad, take in everything you can, but don't presume to know enough to hand out criticism. You'll observe good nurses and bad nurses, this is the time when you'll decide what kind of nurse you are going to be. There is cutting corners for the sake of laziness and then there is doing the best that you can with a given situation. I've never met a doctor or nurse that is 100% truthful in their charting... They may think they are being truthful, but in fact there's usually plenty of wiggle room in the way things are stated in a patients chart. It's a often matter of interpretation and knowing which things are actually relevant to the pt's condition and treatment. If granny takes her pill for high blood pressure every morning, splitting hairs between 930 and 935 isn't going to matter one way or the other.

[sMoLsNurse]

You say you're a new grad OP. I'm just wondering if you are ever late with meds. Coming from experience, when I first started out I was late a lot the first couple weeks. Do you record the time as the current or scheduled time? Has management said anything to you if you do pass meds late and record it as late?

[wooh, BSN, RN]

I absolutely agree. It is, indeed, impossible to pass the meds in time. I certainly don't hold any ill will towards this "hypothetical" nurse for doing what she feels she must to survive.

Here is the issue that has kept me up tonight. This action of falsifying the time of med administration is not without consequence for the patient. It could be unsafe. Also, I feel like it is a serious violation of a patient's rights.

On the other hand, I don't want to get this person in trouble. As you said, she is just a player in the game.

In what world is getting your colace at 10 instead of 8 a "serious violation of a patient's rights"? As someone said, worry about your own practice for now. And if you time to police someone else's practice, then help them instead of throwing them under the bus.

Very few medications are time sensitive enough to make a difference as long as they're given at some point during the morning hours. And you learn what those meds are and work around them. If I've got a q2 pain med or a q6 antibiotic, I try to get those as on time as possible, and work the multivitamins and such around them. My rule of thumb: If it's ordered qXhours, it probably needs to be more on time than if it's ordered x times per day. So generally q6 needs to be given closer to on time than QID.

But, why didn't you just get 8 iv sites?!?!?!? (Please note my sarcasm... =))

Any safe and prudent nurse would!!

the nurse is risking her license and allowing management to get away with creating an impossible situation. As long as she does it, management has no incentive to correct anything. If she gets caught, they just find someone else.

And if she doesn't do it, management still has no incentive to correct anything, because there's plenty of nurses that will. They'll just hire one of those instead.

[ppfd, BSN, EMT-P]

I attempted to try nursing home work part time once. I'm guessing that is what SNF stands for.

I lasted my 4, "training days", and never went back. Now I know why they were paying what they do.

It was almost impossible to care for 30 plus residents and stay on schedule.

I was one of those nurses passing 8AM meds at 11AM. This place had 2 RNs, 1 in each unit caring for no less than 30 pts each.

We had 4 "RN managers" on during the day.

Now I know that when I work EMS and get called to this place why the faces change each time.

There is no way I'd ever work there again.

Reading these types of threads/posts is why I hold the majority of nursing home nurses in high respect.

[BrandonLPN, LPN]

I work in a facility that still uses the "thousands of tiny little boxes in a great big binder" style MAR. Each pill, eye gtt, injection and inhaler has to be initialed every time. When I work 7-3 (I normally work nights) I pass meds to over 40 residents, and there's just no way I could give everyone's meds within a +/- one hour window. Just no way. It's not a culture change issue. It's not an efficiency issue. It's not a re-education issue. It's just not possible. Under any circumstances. Ever.

And, though it takes a new grad or a hospital nurse a long, long time to accept this, missing the "one hour either way" window just isn't that big of a deal. All of my residents will get their morning meds by 10am or maybe shortly there after. Stop and think about it, and you'll realize it isn't a big deal. So mrs smith gets her lopressor at 10am and 7pm once in a while, instead of at 8am and 8pm. Is she going to die because the BP meds she takes every day aren't exactly 12 hrs apart?

As others have said, qid ABX are a somewhat different story, but there are timed in a way to avoid major problems.

Part of being a nurse is having the nursing judgement to realize that giving a routine med a couple hours late is not 911-melodrama-everyone-panic time. If being a nurse means blindly and obsessively following rigid orders and schedules at any cost, then they may as well let Joe blow off the street pass meds.

I haven't read all these posts, but I'm sure many have told you by now that "turning in" this nurse or "taking it further" is a horrible idea.

[BrandonLPN, LPN]

A couple suggestions for easing the med pass burden:

Have the 11-7 nurse give all the AM pills to the residents who get up super early. Every unit has a handful of residents who get up at the crack of dawn. Just have the physician change the 8am meds to 6am for these people.

Better yet, instead of scheduling specific times, have routine meds scheduled for "morning", "lunch" and "HS". I really wish my facility did this. I've heard of other places doing this.

[CaringGerinurse525]

A couple suggestions for easing the med pass burden:

Have the 11-7 nurse give all the AM pills to the residents who get up super early. Every unit has a handful of residents who get up at the crack of dawn. Just have the physician change the 8am meds to 6am for these people.

Better yet, instead of scheduling specific times, have routine meds scheduled for "morning", "lunch" and "HS". I really wish my facility did this. I've heard of other places doing this.

That's how our facility does it. We also have the 11-7 nurses give the early risers their meds. They are care-planned this way and set up with the doctor to ease the AM med pass. I work second shift so having the PM and HS med times are really nice especially with sundowners.

I also believe the facilities and doctors should work together to reduce the number of meds the resident receives. Polypharmacy really is an issue. Our doctor however does not believe this and will just throw our suggestions out.