Need advice on memo to all nursing staff that contains threat

[ms40]

to report all medication errors to state board of nursing.

A bit of background: I work in a State intermediate care facility for people with developmental disabilities. We are currently operating under a settlement agreement that is overseen by the US DOJ. As such there are numerous inspections, reviews, surveys, etc., to measure progress made toward fulfilling the requirements of the settlement agreement.

One of the most recent problems (approximately a month ago) noted by a particular surveyor was that a number of nurses had failed to sign the MAR after giving meds, treatments, etc. When this was revealed the DON and Chief Officer sent out a memo that outlined a new policy of progressive disciplinary action for making medication errors (not signing is considered an error), which to me, did not seem unreasonable. The memo left off by stating that this particular surveyor would return in a few weeks time to spend more time visiting with staff and residents which I am presuming was a bit of a "heads-up".

The surveyor made the return visit and found unsigned MAR's still an issue in some units. Some had been presigned (yikes!). There is no doubt in my mind that there are some big problems. Here's how the administration has chosed to deal with this issue. Yesterday, we received a memo from the DON and the Chief Officer regarding another new policy on disciplinary action for failing to sign the MAR or any other medication error. It is now facility policy to immediately fire a nurse that makes an error regardless of the circumstances. A strict "no-rehire" flag for negligence will be placed in the offender's personnel file and, I assume also passed on to any future employer. The facility will also report any medication error, and the offending nurse, to the State Board of Nursing for investigation.

I suppose the facility can make any policy that they like, but this seems wrong on so many levels. What recourse would I have for example, if I get fired and reported to the BON for forgetting to inital the MAR on the 1100 administration of Boost Pudding for patient "X"?

I would appreciate any feedback, words of wisdom, etc., that any of you have to offer on this situation.

[canoehead, BSN, RN]

I think that the policy is heavyhanded, but fair, although if they make a policy like that they have to be willing to live with the consequences. If they fire everyone who makes an error they may be spending half their budget on recruitment/hiring. Strategy here being not to make the first or second error, and by then the issue will have been resolved one way or another. Perhaps they know they want to get rid of employee x and y, then it'll be a policy on paper but not in practice.

[Nurse Ratched, RN]

I also have to wonder what is the main obstacle to getting MAR's signed off. Like Renerian, I might suspect understaffing (like if you have to interrupt your med pass to prevent people from falling on the floor, or to help someone on the commode, then you might tend to lose your train of thought?

How many patients is each nurse responsible for? Are your duty expectations in line with reality?

[oldiebutgoodie, RN]

How hard is it to sign an MAR? I have it so ingrained into me as a nursing student, that I can't leave the room without signing it. However, we have doorside charts, so the MAR is right there.

I dunno, if the staff can't sign their name, there seems to be a problem.

Oldiebutgoodie

[FROGGYLEGS, LPN]

How hard is it to sign an MAR? I have it so ingrained into me as a nursing student, that I can't leave the room without signing it. However, we have doorside charts, so the MAR is right there.

I dunno, if the staff can't sign their name, there seems to be a problem.

Oldiebutgoodie

I agree with what some of the others said about the possiblity of underlying causes.

I am not trying to justify the nurses failure to sign.

When I was in nursing school I had a few patients and I doubt I left any blanks on their MARS. It is more difficult after you graduate. My MAR is now bigger than the policy and procedure manual. There is just more room for error now.

[kmchugh]

If you think administration is being heavy handed in this case, consider this. Suppose the OP followed the advice of many of you, and quit. Let's look at her next job interview, if she were completely honest:

Interviewer: So, why did you leave your last position?

OP: Well, the facility got really unreasonable and heavy handed. They not only expected that nurses were to give all meds ordered and on time, but expected the nurses to document that appropriately.

I: And that's when you quit?

OP: Oh, no. I knew their expectation was unreasonable, but I toughed it out.

I: So, what happened?

OP: Well, we got inspected by the state, and got dinged for not passing and charting meds properly. Administration put out a memo requiring us to do the meds right, and warned us that the inspectors were coming back. It was after the inspectors came back that administration really went overboard!

I: How so?

OP: Well, the inspectors came back, and found the same mistakes being made.....

I: Wait, you knew they were coming back, but were making the same mistakes?

OP: Well, yeah! I mean it's not like its a big deal or anything! I mean sometimes, the "med" was just boost pudding! Anyway, after the inspectors came back and found the same mistakes being made, administration got unreasonable. They said they would fire any nurse who was not passing meds correctly or not charting that pass properly. Really! Then they would report us to the state board of nursing! Really! Like we were doing something wrong!

I: And that's when you quit?

OP: Well, yeah! I mean, I can only take so much, you know?

I: Thanks for your time. We'll get back to you if anything ever opens up. Have a good life.

It seems to me that the staff are the ones being recalcitrant and heavy handed here. They are the ones who are not only being stubborn about fixing a deficiency, but about trying to keep the doors of the facility open. Giving meds appropriately, then documenting that is basic nursing. We all make mistakes, we are human. But this goes beyond simple mistakes. This is a refusal to follow basic nursing guidelines. Or did I learn something unique in my nursing school?

Edited to add: My point is this: If you think administration is being heavy handed, what do you think they should do? They have been dinged for med errors and improper charting once, and put out a reasonable policy to remedy the situation. Staff ignored the policy, and continued to make the same errors. The inspectors returned, and dinged the facility for continuing to make the same errors! Again, what is administration's recourse, but to become heavy handed?

Kevin McHugh

[elkpark]

I am a nurse who works as a surveyor for my state licensing agency and CMS (after many years of working as clinical staff, so I have been on both sides of the fence), and, while I agree that the situation you describe is difficult and unpleasant for the staff, what do you expect the administration to do? It is v. serious business to be in trouble with CMS or DOJ (or even just your state licensing agency) on an ongoing basis. The facility is looking at losing its license or its ability to receive Medicare/Medicaid money (which, these days, is basically the same as padlocking the doors ...)

While the original med errors that got the facility in trouble were probably not "just" Boost pudding (the facility would have had to have a pretty serious pattern of significant med errors to get cited initially), now that the process of monitoring for correction of the problem is underway, ANY med error, however minor, is an indication that the problem is not corrected.

Unfortunately, the bottom line is that, as other posters have pointed out, we all know that an unsigned MAR is a med error (and a presigned one is fraud!) There isn't any footnote about how it's ok as long as it's not a "serious" error. What's wrong with be held accountable for your professional practice?

[Blackcat99]

Interviewer: Why did you leave your last position?

Answer: I had a medical emergency during my medication pass. Silly me I saved a patient's life and therefore I accidently forgot to sign off that multi-vitamin pill. I was fired because the policy was "Fire a nurse that makes an error regardless of the circumstances" The firing will make me a better nurse now. In the future, if I find any kind of medical emergency,or patients falling on the floor or hysterical family members during my med pass I will just ignore them all. After all, What could be more important than signing those med sheets?

[elkpark]

Interviewer: Why did you leave your last position?

Answer: I had a medical emergency during my medication pass. Silly me I saved a patient's life and therefore I accidently forgot to sign off that multi-vitamin pill. I was fired because the policy was "Fire a nurse that makes an error regardless of the circumstances" The firing will make me a better nurse now. In the future, if I find any kind of medical emergency,or patients falling on the floor or hysterical family members during my med pass I will just ignore them all. After all, What could be more important than signing those med sheets?

Cute, but ... Sorry, the reality of nursing practice is that your obligation to respond to the medical emergency does not relieve you of the obligation to document the medications you gave. It's such a shame that nursing is such a darned hard job!

[movealong]

Signing MAR's is basic stuff, very basic. I don't think it's unreasonable to want this to be done. I've been out of hospitals for 6 years now, has it changed that much? Presigning? What the heck is going there? Something must be very wrong there, either you guys are shortstaffed, or I just don't know.

I don't mean to come off sounding horifice, but good grief, signing MAR's is just something you do. Period.

But I think the policy regarding it could be better. However, assuming what they place in one's file will follow you, it's unlikely. Most places now only verify that a person was employed with them. No details given out.

[suzanne4, RN]

I would have to side with Kevin on both of his posts. And wonder what type of policy do they have in place for medication administration to begin with? Do you use a cart system, or go back to the med room for each patient's meds? Where is the MAR when you are passing meds? :uhoh21:

[Stitchie]

I don't work 'a unit' anymore; I'm in the ER so it's a bit different for us. When I did work the floor I often had patients with 5-7 pages of meds. Since these patients were long-term vent patients, the meds were v. important.

You might think that 4-5 patients isn't a lot; but it would be v. heavy patients; trach patients, vent patients, lots of dressing changes, lots of tests and every consultant you can dream up writing orders.

While I agree that charting the med is the nurse's responsibility, and vitally important, I also think that ANY policy that comes across as heavy-handed won't promote the retention of nurses.

Everyone has forgotten to sign out a med, including me, as well as nurses that worked for years. We gave a them a call at home to straighten out the problem and charted 'given by AM/PM/NOC RN' and that was the end of it. Sure some were bigger offenders than others. I checked the MAR's before I left and made sure that all my meds were signed out or explained why not given. Even if it took me an extra 10 minutes a day. I was a v. slow floor nurse.

If it's difficult to do this on an inpatient setting, I understand that if you have 20 NH patients to pass meds to it can be overwhelming. So the question is are you staffed safely and adequately?

With pressure like that coming from above any kind of heavy-handed, black and white 'policy' becomes punitive and eventually all staff will hang for it. While it's true that the issue needs to be addressed this sort of 'fired for one infraction' is only going to generate a sense of fear and mistrust among the staff.

I think that this policy can be applied unevenly and to the detriment of particular nurses. I think that policies such as this do nothing to promote a professional image of nursing when we get punished like naughty children for an understandable error. A more evenly applied policy could be substituted for this; this sounds as if trouble will come eventually, knocking on those few nurse's doors who choose to stick it out. JMO.

[Lela RN]

Document no matter what. You should come in early and check your MARs so you will know what you have to give and check to make sure none of the meds due from the previous shift need to be given on your shift, due to new orders or if meds were unavailable from pharmacy. It's annoying to come behid a nurse and find meds not signed off, especially if the med was due at like 2200, and I come in at 2300, I can't assume it was given nor do I know if I need to give a late dose. I had to look up that nurses home # to find out if she gave it or not. Time that I could spend doing other things during my own shift. Sign off and double check before you leave. It's a matter of patient safety, this is most important no matter where you work.