new charge nurse discovering bad practice on the unit

[nursindaz]

I have recently been named as the full time charge nurse on my unit and I have come to soe unpleasant discoveries. I am not sure exactly what to do.

I found out that another RN on my unit has been giving her patients their bedtime meds at 4,5,or 6 pm, instead of 2200 as ordered. Apparently the previous charge was very aware but tired of the BS (retired now after 50 years of experience) and never really addressed the issue.

I asked the nurse why she was giving meds so early and she bold faced lied to me, told me "because the daughter asked me to give her her meds now" SO I couldn't really call her a liar but I audited her other patients med sheets and several of them were the same...now the thing is, she didn't change the tmes to accurately reflect when she gave the meds, so I KNOW she knows what she is doing is wrong.

the issue I have is that she wanted the charge position BAD and thay gave it to me, I don't want her to think I am singling her out. I also don't want to make too many big wave my first week on the job but this is really bothering me. How would you handle this situation? Any input would be helpful.

[nursindaz]

theses meds were things like Cipro, which the patient recieved at 10am, then she gave it at 1600. also coumadin, which is specifically ordered for 2200 (for ortho pateints) , which she gave at 1600. I checked the accudose and it showed that she pulled the meds at 1553,but she left the times on the MAR at 2200. so unless she forgot to change the times (on three MARS) she knows that the meds should be given at specifically designated time.

I think I will talk to my manager, the pharmacy should be able to audit her charts for pulling medications and falsely documenting the administration times. All of our meds are stored and dispensed from a computerized system.

I think I should write it up as a med error. Then it is out of my hands as to what disciplinary action our manager takes. (And how many offenses the pharmacy finds.)

[SuesquatchRN, BSN, RN]

theses meds were things like Cipro, which the patient recieved at 10am, then she gave it at 1600. also coumadin, which is specifically ordered for 2200 (for ortho pateints) , which she gave at 1600.

That's what I was saying I wouldn't do. I was thinking colace and mevacor. She's doing things that could be harmful and this practice needs to be stopped.

[Simplepleasures]

Honestly I think she is just being lazy and grouping all of her meds together to save her from having to get off her butt and actually do her job (the correct way). The thing that bugs me is that I always go to the staff I am woking with and ask if they need assistance and she always seems so calm and put together. The reason is of course because she knows that all of her meds are passed and she can just enjoy watching every one else run around.

Yes, we are a fairly busy floor, although small. We are an acute care/ orthopedic specialty unit. on any given night (3-11pm) we will recieve 5-6 post-op total joints. We generally have three RN's, 2 CNA's and a unit clerk.

Thanks everyone for your input.

I dont know if she was being lazy or overworked and trying to get a step ahead if something went sour later on.I dont condone it , but I do understand that hurried overworked nurses do all kinds of things they shouldnt in order to get out the door on time. The nurses who do everything by the book are the ones who get hauled onto the carpet for too much overtime. This is just another symptom of a very SICK LTC industry.

[snowfreeze, BSN, RN]

As a new charge nurse of this unit you need to establish your own code of behavior. Yes you will find things that don't mesh with your own ethics and rules. Establish your new rules and stick to them. Some will not like it, most will eventually follow. Forget the old rules and remind all staff when they confront you privately that the new rules are what they will follow. Many will try to re-establish what worked for them in the past, don't allow that. Stick to your guns and support staff when it involves the facility and staffing issues.

[P_RN, ADN, RN]

Im curious why is coumadin ordered for 8P? Are your patients getting daily INRs at 8 am? Usually it's given 12 h after the blood draw.

[nursindaz]

Im curious why is coumadin ordered for 8P? Are your patients getting daily INRs at 8 am? Usually it's given 12 h after the blood draw.

2200 is 10 pm. for some reason there is a policy on our floor that for our ortho patients, they want the coumadin given at that time. I have talked to one of the docs and he says that it is when it is best absorbed in relation to meals, and the timing of the PT/INR at 0500. They dose acording to that days blood draw for coumadin. so if the patient recieved it six hours earlier than they know, they could be dosing the coumadin at higher levels than they would if it was given at the ordered time.

I don't know, but to me a fresh one or two day post op total joint should have their meds followed to a T, according to what is ordered. Especially if it involves a high risk drug like coumadin.

Calgon, take me away!

[Daytonite, BSN, RN]

When you are in a new position with a big problem like this, I think the best thing to do is to sit down behind a closed door and talk with your supervisor or manager and tell him/her what you have discovered and ask for guidance in how to handle the problem. It will also give you a good indication of what kind of boss you have. This way, you will have your boss' backing as well as a plan of action in place. Good luck!

[sming]

I have given meds early, but it depends on the situation, and what the meds are. I work in a busy CCU unit, and if I have a heart rate that is much higher than it should be in a fresh MI, I would give the oral beta blockers and let the MD know, and I chart in my notes what I have done. In the MAR I put the time in as to the time they were given with an nn see nursing notes

In the morning, if all the pills are od, and I am giving an pre meal med, I see nothing wrong in giving them all at the same time

Then on other occations, if I am giving three meds that all affect the blood preasure, I will stagger them. All is charted and up front, it is an individual decision, for individual situations and a bit of common sence. One must know the drugs inside out as to what there effects are etc. and ya if a patient is sleeping early I see no problem of giving them early if there are no indications not to do so. These people the patient has to go home and be complient. If a scheduale is too ridgid and too complicated the patient is going to go home and miss medicate themselves

[littlebear]

Being a psych nurse some of the abbreviations used so far are a little baffling, but i think i have worked most of them out! This issue cannot be brushed under the carpet, but i don't believe you should be soley responsible for dealing with it. If the meds being withdrawn are recorded electronically then the evidence is there for all to see. At the end of the day why on earth are the docs not just being asked to change the times. The management structure within my department is great. I appreciate it is not the same everywhere, but this is definately something that should be taken to management.

[truern]

Am I missing something here?? When I take off orders for meds unless there is a specific time ordered I can pretty much make it whenever I need. For example, if they already have an 0800 ordered, then any new once daily meds are also 0800. If the patient's usual bedtime is 2100, then any HS meds are scheduled to fit the patient's routine.

Is your pharmacy deciding on the timing of administration??

[augigi, CNS]

Depends if the doctor has ordered the time of administration.

[gitterbug]

The inservice is a great idea, with emphasis on facility policy and procedure. Be sure to include group discussion for insight on problems the nurses may be having giving certain meds at certain times. Our Coumadin was changed to 1700 d/t so much flip-flopping by lab. No matter the excuse after the change, PT-PTT,INR could not be drawn earlier than 0430 for once daily draws. Q 6 hr draws were timed accordingly but we all felt we were getting more accurate readings by sticking to the schedule.

I worked with nurses who pulled HS meds early but did not give them except by schedule. How do I know? I watched to make sure. I would talk this situation over the my manager, have her pull some of the old MAR's, review them, and let this nurse know her actions are dangerous, out of policy, and need to be revised or she needs to resign. Good luck, it is never easy to be the new boss.