How much autonomy?

  1. The facility that I recently left had standing orders for nitro for chest pains and treatments for hypoglycemia. The nurses had the autonomy to assess the patient and treat accordingly. My new facility does not have any standing orders or allow this autonomy. On top of this they allow doctors to practice who do not see their patients as required by law and the DON has posted notes not to call these doctors because they don't want to be bothered. We are allowed to fax only unless it is a life threatening situation. In one situation this weekend it took the doctor 4 hours to respond to a call for emergency. In the meantime, I treated a patient for "lo" blood sugar, nonresponsive... I gave glucagon injection. Our policy calls for IV start and D50 infused but I was unable to start an IV as the patient has NO veins. Now my DON is threatening "you could lose your nursing license for this" I guess my question is What would you all do? Her biggest thing was I broke policy by giving glucagon when I was unable to start the IV and I did it without hearing from the doctor. Her words were practicing medicine without a license. Perhaps I should of waited the 4 hour response time?....
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    About longtermcarern

    Joined: Sep '02; Posts: 117; Likes: 6


  3. by   whipping girl in 07
    I work in ICU and we have quite a bit of autonomy; lots of standing orders and of course, ACLS protocol. If the doctors who practice at your facility don't see the patients like they are supposed to, isn't there someone you can report that to? Our Department of Health & Hospitals is the agency of oversight for nursing homes and LTC facilities.

    Not returning a call for four hours is unacceptable. How many times did you call the doctor? Did you document each time you called? We have a couple of doctors who are bad to not return phone calls, and we just keep calling the service, leaving the message and documenting everything. If I call a doctor and they do not want to give orders, I always document "Dr. So&so contacted with...(assessment data). No new orders." If the doctor says not to call him/her again, I also document that as well, both on the orders page as a verbal order and in my nurse's notes.

    If it was me and I could not get these problems fixed after reporting them, I'd have to move on to a better managed facility. Sometimes you just have to vote with your feet.
  4. by   globalRN
    first that doctor should be written up for not responding in a timely manner.
    second, family members are often taught to give glucagon to their diabetic members if they are was a reasonable alternative to no IV access(understatement)
    If there was an order to start an IV and give d50 and you couldn't
    in the scenario you described...I can't see losing your license
    for doing the right thing???
  5. by   SharonH, RN
    Well first of all, the policy sucks. There should be an alternative for what to do if the resident doesn't have IV access or if you are unable to get IV access. Secondly, if your DON thinks the board will have a problem with what you did then what would your state think about a doctor taking 4 hours to respond to an emergency phone call?
  6. by   Youda
    Your facility sure has put in you a Catch-22, longtermcarern!!!

    All state BONs have exceptions for life-threatening situations. As long as you were acting within your training and experience, you are fine with the BON. (Like if you aren't trained for a cut-down, open-heart massage, you probably shouldn't try it. But giving an injections is well within your training!). It is always amazing to me how many NMs go spouting off about licensure issues when they have obviously never read their state's Nurse Practice Act!

    The best, positive thing you can now accomplish is to use this event to get the policy changed; and work for better responsiveness with the docs. You're in a really bad situation there. Consider if this is a good place for you (or any nurse for that matter).
  7. by   sjoe
    My understanding is this:

    The tasks you are permitted to perform are determined by each state's BON, so you might want to consult them to see what your scope of practice includes.

    If the tasks you performed were outside your scope of practice AND there were no standing orders or facility policies to cover your actions, then you are in breach of your state's rules. It would be good to have a copy of, and be familiar with, these regulations for the future.

    No point in worrying about it now and you were wise to document everything (and, I hope you kept a copy of all this stuff for yourself--at home), as always is the case when there might be a question.
    Last edit by sjoe on Oct 14, '02
  8. by   ceecel.dee
    I agree with Youda. This incident should open up dialog about the need for some standing orders, the need for doctors rounding on their patients regularly, the need for personal communication (rather than fax) between the nurses assessing the patients (residents) and the treating physician. Insist on this dialog! Your DON has become lax in what she expects from the physicians, and is now defensive about the dialog that needs to take place. You are in the position of "change agent" now, and it really benefits you to have worked in a more nurse-friendly place to make direct comparisons with. Your coworkers are lucky to have you, not to mention that hypoglycemic resident who's life you saved!

    Rock on, good nurses!
  9. by   deespoohbear
    I can't believe that the families of the residents allow the doctors to get by without seeing their loved ones. Here in Indiana, the doctor is required to see a patient in long term care every 60 days (every 30 days for the first 2 months for a new admission). I can't believe the state board of health hasn't caught that on inspection. Maybe it is time for an anonymous phone call to the state board or the ombudsmen for your facility. All long term facilities should have policies in place for chest pain, hypoglycemia, and other life threatening emergencies. What is your facility's policy on calling 911? Are you allowed to do that or does that require a doctor's order to transfer? My belief is especially if the person is a full code and is showing s/s of a life threatening emergency, you should be able to summon EMS without having to go through the doctor first. LTC's are not usually equipped to deal with code blue situations (not being able to have access to radiology and labs and such). Your facility's policy stinks and needs changed or you better look for another facility....IMHO....
  10. by   longtermcarern
    Thanks all for your thoughts. State rules for doctor visits are q 60 days and some of the docs have only seen their patients 1 or 2 times in past year. I should also mention that if this was a for profit facility, the inspections would of nailed this a long time ago, but this is a county run facility and there seems to be a whole seperate set of rules or at least a different way of surveying them. I have been thru many surveys and the glaring things I have seen here would of bought level G's at other facilities but don't get cited here. Calling for EMS also requires a doctors order here.
  11. by   Agnus
    You a nurse need an MD order to call EMS. Funny any Joe
    Blow on the street can call EMS.
    This stinks. This is allowed to happen because society sees these folks as a throw away population. They are old, sick and being in a county home are a drain on taxpayer's money.

    Perhaps if some of those tax payers Knew how their money was being used they would be upset. I am certain that these Docs are stilling collecting money for seeing patients every 60 days weather they do or not.

    They may be run by a county government but I wonder what the State health and welfare or the federal folks might have to say since they are no doubt getting money from these sources, as most counties do. There are possibly private grants that they receive and thier benifactors might like to know what is going on.

    Your Don is out of line. I would venture to guess her license is at risk by her behavior.

    I agree document document, document and keep copies. Talk to the DON talk to the physicians. Or Walk!