Hi guys, I'm looking for words of encouragement or success stories.
I'm an ER nurse with 6 years of experience. The past 3 years I've been having the time of my life doing travel nursing. unfortunately my last contract was cancelled 4 days before my start date because of low census ("we hired too many nurses - sorry"). 2 days after this cancellation I'm notified by the board that I have a accusation against my license.
Early last year (2019) I had a emergency verbal order to restrain a confused patient that came into our department in respiratory distress. The patient was pulling out lines and grabbing at the nursing and RT staff. After the ABG came back the physician ordered BiPAP and the patient was placed on BiPAP while restrained. Long story short the intensivist came down stairs and found this patient restrained while on BiPAP and was not happy.
The ER MD denied any knowledge of the restraints and the intensivist reported me to my agency who then in turn "had to" report me to the board.
Now, a year later, and after 6k in lawyer fees, I'm facing the possibility of probationary measures placed on my license.
As I write this I am unemployed in central California. My agency states they cant work with me until the case is closed. In spite of shining letters of recommendation by every job I've ever worked facilities won't interview me with the pending investigation. My last contract wants to hire me but everything is on a hiring freeze because of CoVID - 19.
Has anyone been through this and can you offer words of encouragement or advice?
I'm stuck here in my lease away from home and ruminating about all the possible negative outcomes. Nights are long and days are slow.
It seems you were given a restraint order before bipap was placed.
You absolutely cannot have a patient who is on bipap in restraints. The reason being if they vomit, they cannot take the mask off resulting in that vomit being pushed into the lungs thus aiding aspiration, and possible death.
To anyone questioning this, please do not ever put your patient on bipap in restraints. It’s very dangerous. The restraints should have been removed as soon as the patient was put on bipap.
I get that it’s an aspiration risk, but reporting to the BON seems excessive. How about “this is a safety concern; what other options do we have?” (eg nasal-only BiPAP, anxiolysis, 1:1 sitter.....)
Specializes in Advanced Practice Critical Care and Family Nursing.
The darkest hour is just before dawn, and believe it or not you will be thankful for this experience. As nurses we genuinely desire to maximize and teach the intrinsic value of each and every person. Yet while enduring the reactionary consequences of fear from those very people, we ourselves can fall prey to our own nihilism. Abandonment, blame, feeling victimized, are all very human emotions and rather foolish to ignore. However, no one can endure that dark place for long. Nurses are often dubbed "heros" for various reasons, and rightly so. Heros rise to the top of every situation, they run to the dark cave everyone is running out of, they slay the dragon everyone is running from. Heros climb the tower to save the princess, and tolerate the flames of burning homes to save strangers.
So you're in this dark cave, the scared ER doctor threw you to the flames when his colleague legitimately questioned the restraints. Now the BON, who is the dragon, wants to eat you like a tender morsel, as they do every nurse in their gaze. Best thing you did was get an attorney, let them do the priceless dirty work you're paying them for. Hopefully the patient was not harmed, and if that's the case you'll be fine. Learn everything you can from this, because if I've witnessed and experienced anything in my long career it's the nativity of nurses. Be the hero, not the victim. Slay the dragon.
Specializes in Psych (25 years), Medical (15 years).
On 4/30/2020 at 4:10 PM, LovingLife123 said:
You absolutely cannot have a patient who is on bipap in restraints. The reason being if they vomit, they cannot take the mask off resulting in that vomit being pushed into the lungs thus aiding aspiration, and possible death.
You make a very good point, LovingLife.
However, if a patient is in restraints, they are considered to be a 1:1 and the sitter, who ranges from being a Tech or CNA to an RN, is required to be within an arm's length.
I have no experience with a patient in restraints being on BIPAP, so all I can offer is conjecture.
Specializes in Psych, Addictions, SOL (Student of Life).
On 4/28/2020 at 5:43 PM, chare said:
Reported you for what, exactly?
I'm trying to see how not having a signed order for restraints warrants a report to, and subsequently t investigation by the BON.
Best wishes.
It is unlawful to physically or chemically restrain a patient without a signed physician order. In some cases if restraint is applied during an emergency the Doctor has 1 hour to sign off on the order.
However, if a patient is in restraints, they are considered to be a 1:1 and the sitter, who ranges from being a Tech or CNA to an RN, is required to be within an arm's length.
I have no experience with a patient in restraints being on BIPAP, so all I can offer is conjecture.
Not in the hospital. I often have 2 patients in restraints and we never order a sitter for someone being in restraints.
Specializes in Psych, Addictions, SOL (Student of Life).
4 minutes ago, LovingLife123 said:
Not in the hospital. I often have 2 patients in restraints and we never order a sitter for someone being in restraints.
This has nothing to do with having a sitter. I have worked in acute hospitals and it has always required a written Doctors order or a sign off on a verbal. In the acute setting I have worked those orders need to be renewed every hour. In psych where I now work an adult cannot spend more that 4 hours in restraints, Adolescent no more than 2 hours and children are 1 hour or less
I had patients in restrains and on Bipap quite a few times, both as a bedside nurse and as provider. Sometimes this is only one thing that can be done if "as much sedation as you need but just enough of it" tactic is not an option.
These people need to be watched as by hawks not that much because of potential aspiration - that can happen without Bipap just as well - but because they by definition sit on a very thin line between agitation and oversedation. Agitation increases oxygen consumption and worsens hypoxia and hypercapnia, oversedation decreases respiratory drive, wiggling in between makes the management difficult. They go into severe acidosis with amazing speed, for one thing. They may or may not need a sitter - especially after sedation finally kicks in - but they need very intense level of assessment because they can go South at any moment.
Honestly, when I was called at 3 AM by a nurse asking for something, I did not remember anything at all about it next morning in at least half of the cases. That included ordering restrains. I do remember, though, that in case it was a verbal order, it must be repeated second time to another nurse and then renewed every 4 hours for adults with double sign off. Where I am now, any patient with restrain order must be seen within 60 min., Bipap or not, no exclusions.
I feel very sorry for the OP. She was possibly just thrown under bus by someone who was too busy to think out some one sentence justification for order to cover HIS OWN butt first (as I am 95+% sure that the question was about ER physician initiating order and either not performing assessment or not signing off and then poor unhappy ICU doc was left with that scutwork to do plus his concerns as above).
On 4/28/2020 at 7:20 PM, aspirationpneumonia said:
Early last year (2019) I had a emergency verbal order to restrain a confused patient that came into our department in respiratory distress. The patient was pulling out lines and grabbing at the nursing and RT staff. After the ABG came back the physician ordered BiPAP and the patient was placed on BiPAP while restrained. Long story short the intensivist came down stairs and found this patient restrained while on BiPAP and was not happy.
The ER MD denied any knowledge of the restraints and the intensivist reported me to my agency who then in turn "had to" report me to the board.
I'm stuck here in my lease away from home and ruminating about all the possible negative outcomes. Nights are long and days are slow.
Any advice, please - no negativity.
That your complaint is about “Verbal orders” may save you, or break you. I prefer the term VORB (Verbal order, read back).
This document is a Nebraska BON advisory, and well worth reading by any nurse.
Notable in Nebraska (remember, different states = different rules) is:
“Facilities are responsible for policies and procedures that identify conditions for the acceptance Verbal Orders page 2 and implementation of verbal orders. The patient medical record must necessarily allow for documentation that provides a retrievable record of the communication between the prescriber and the nurse…”
“Verbal orders must always be transcribed to the patient medical record by the nurse.”
And, very importantly (should your state mimic Nebraska’s rules):
“Verbal orders are subsequently reviewed and authenticated by the prescriber. The prescriber must cosign or authenticate the orders to validate the order.” Read: The doc is in violation if he/she did NOT do this on your order or others.
For you, a few questions:
1) Was it read back?
2) Did you enter it into an electronic record?
Your requirements are to take the order, read it back for confirmation, and enter it into the medical record.
If you did not enter it into an electronic record, you are likely out in left field. But if you did—it is irrevocably locked into that record. Not only that, a time entry notates the time that ER doc called and sometimes that call can be traced. For instance, Doc states: “I deny any knowledge of such an order by me.” OK, please explain to the Court just what the call that you placed at 3:10 to the ED from phone number was for? Uh oh.
Also, why would you enter, contemporaneously, or even later (but not much later) the order, if it was not called in?
Forget the agency. Why? Because even if the agency is found to have maliciously written the complaint, (not the case here) it is likely “privileged.” In short, legal action in this case, by you against the agency will fail. Sad, but true (in most states).
Interestingly here, you may have a positive aspect. Here, it was the intensivist who reported you, not to the BON, which would have been privileged and non-actionable in Court, but rather to your agency, which is likely, not privileged, and is likely actionable.
In short, if the intensivist reported you to BON, you’d be out in left field and could not file an action based upon defamation. But you could (remember, state rules rule) possibly, file for defamation to the interventionist, or to the hospital who may “own” the interventionist.
Let’s assume that you did read it back, and entered that in the medical record. You say that the doc denies any action.
But the rules (if in Nebraska) requires the Doc to “Verbal orders are subsequently reviewed and authenticated by the prescriber.” Did the doc fail the rules? What about other “verbal orders?” Oh, perhaps the doc has NEVER complied—this may be hard to prove, but it is provable.
Now, back to reality. You’ve spent $6,000 and in reality, your lawyer probably hasn’t covered what I’ve covered, and probably has created an extremely costly POC as “answer to BON.” (POC = Piece of garbage). (This may also not be the case.)
From what I’ve seen, lawyers, even ones that do this sort of stuff, who routinely (represent nurses) charge a lot, and give little. I’m sure that there are very competent lawyers and I’m fairly sure that they are likely very rich. To “fight” back by asking the BON to allow you do discovery to pull the medical record showing you 1) entered the order and 2) the doctor called the unit on that day, at that time, is not particularly difficult but such actions cost. Remember most lawyers want cases that return $100k or more.
Most nurses cannot tell a good work product, so there may be little impetus to create one.
Should you obtain by subpoena a copy of the entered order (with identifying information redacted) and a copy of call records, it is possible for you or your lawyer to present this to the BON. Judges (and BON act as “judge,” loathe lies. Catch an opponent (such as the denying doc) in a bold-face lie and you may find the entire case dropped. A copy of the med record (redacted) time/date stamped alone may well get you off the hook and place the doc in a position of your being able to file defamation against that doc. (Practicality will not be discussed here). Your lawyers should have gone over these options.
Now let me back up a bit. Most BON’s have an action “tree.” Often it goes like this: “Was the patient harmed?” If yes, then, “Was there serious harm?” Other aspects may be intentionality. Here is a link to New Hampshire BON “regulatory decision pathway.”
If you just miffed the interventionist, but there is no record of significant harm to a patient, the BON is not likely to crucify you. See NH for actions that are possible, “supervising, focused remediation, counseling/coaching, is not so harmful.
You say: “my last contract wants to hire me, but everything is on a hiring freeze.” Hopefully you have discussed the complaint to this contract and if so, Covid-19 besides, it’s likely that at some time you’ll be back at bedside.
A few side-notes. BON’s are NOT a nurse’s friend. They are a regulatory machine. It’s not personal—they serve patients, not nurses. A complaint will be dealt with by their pre-determined process. It’s slow, often archaic, and often in violation of Constitutional Rights (both US Constitution and often, more importantly your State Constitution). It's undoubtedly slowed even more by Covid-19, even though most "investigation" can be done by the investigator from home.
For the naysayers on “Constitutional Rights,” see:
“The Constitution prohibits states from depriving citizens of their property rights without due process. For nurses accused of professional misconduct, this means that they have the right to notice of the charges and the opportunity to be heard in their own defense. Nurses who have had adverse license determinations, therefore, may appeal those decisions.” The reality is most states make it difficult or impossible to do so. Florida is becoming the exception and hopefully nurses will be protected by the Constitution sometime in the future.
Had you taken out a $111 per year insurance policy you’d likely be in a better position. See: https://www.nso.com/Get-a-Quote. Readers: Consider such a policy. Many complaints are not made in good faith, a bit of protection may go a long way.
Interestingly, I have been told by a lawyer who represents nurses, “you don’t have to tell anyone (applying for work) that you are under investigation for complaint.” I disagree and say that ethics do require you to self-identify if the job is in nursing. If you go to work for Home Depot, you don’t. The reality is this: Nurses are presumed guilty until proven innocent by the Board of nurses. Everyone else in America is presumed innocent until proven guilty.
This has nothing to do with having a sitter. I have worked in acute hospitals and it has always required a written Doctors order or a sign off on a verbal. In the acute setting I have worked those orders need to be renewed every hour. In psych where I now work an adult cannot spend more that 4 hours in restraints, Adolescent no more than 2 hours and children are 1 hour or less
You are misunderstanding. I’m not in Psych. I’m in an ICU in a hospital. Restraints are renewed every 24 hours and documented on every hour. I could not imagine renewing every hour.
I’m guessing in a psych facility there are not patients on bipap. I’m talking about a hospital setting. 80% of my pod was in restraints today. No sitters.
This nurse was referring to an acute care, medical setting, not a psych setting. I’m sure the rules are different. But it is standard that every patient who is intubated or trying to remove medical devices are restrained. But you absolutely cannot restrain a patient on bipap.
Davey Do
10,666 Posts
Absolutely! A patient in restraints needs to be under direct observation.
Thanks for clarifying that point, as it was not made clear if the patient even had a sitter.