Unsafe Practice by Coworker

[EmpathyInAction]

I started a new job about 10 days ago working in a SNF where my patients still need a lot of acute care. Patients with fresh surgical wounds, feeding tubs, PIC lines, etc. With serious conditions. The nurse that I typically relieve has some really bad habits including leaving meds where they shouldn't be. The thing is that apparently she has been doing this for a while and the other nurses I have been training with are like "oh, ya, she does that". She has a lot of bad habits, the meds is just the worst of it and everyone acts like it's normal. She's leaving meds that she has pulled to give to patients in random places in the med cart. Like a cup with 5 or 6 meds just sitting in the cart. Her logs show she has given all her meds but then I find two or three of these cups in the cart. To me it means that people aren't getting their meds (including narcotics). I just don't really know what else to do since this is considered normal to my coworkers. I talked to some friends who are nurses and they said basically to talk to her and don't tell. I don't want to be an outcast in a new place, but I really feel like this is something that should be corrected and not view as "ok cuz it's typical". It shouldn't be typical. Thoughts?

[Postpartum RN]

I used to work in a snf, it's super busy and I would try to take short cuts where I safely can. Sometimes that meant prepping meds in cups and labeling them and then giving to my pts so that med pass went faster, but I never Prepped too many at once. Noc shift seemed to do that more. Sometimes I would find meds in cups when I came on shift and what I did is take it to the nurse who left the meds there, sometimes her response was that pt refused the meds, so I asked the nurse to update the mar if pt refused and take care if the meds. What i would suggest is checking the med carts before the previous nurse leaves and if you find cups of meds then bring them all to her and say "you left these in the med cart, please take care of them and update the MARs"

We always did a narcotic count at shift change, so at that time is when I would check the whole cart real quick to make sure there are no loose meds and if there are then give them to the nurse. If she refuses to take them, your job is to dispose of the meds properly. You cannot document what you are disposing of since there are no labels on the meds. I think if you consistently bring the meds to that nurse that she leaves behind, she may get it that it's not ok and you won't tolerate it like the others do. It seems that the other nurses are used to it and probably don't hold her to her actions, so you need to show her right from the start that with you this will not pass.

Working in a snf is hard, expectations are high and pt load is high and RNs get little to no respect from other staff (atleast where I worked)

is this your first job? Good luck

[EmpathyInAction]

My first job was in a LTC facility. I was on the skilled unit but the patients didn't require the level of care that the people here do. I understand to an extent setting meds you have pulled and couldn't give right then in with that patients meds. The problem is they are randomly in drawers. I've not thought of checking the drawers before she leaves. That's a good idea. The narcotics really make me nervous. Her counts are always off and she has to fix them when we are counting... then I believe I find them in the drawer. I'm just worried for the patients and that this is going to come back on me negatively.

[BrandonLPN, LPN]

Well, have you tried talking to her? Your friends are absolutely in telling you to talk to her before taking any further action. That's a professional courtesy.

I would have talked to her the first time I followed her and found ungiven meds in the cart.

[Whispera, MSN, RN]

Talk to her. You can't let this slide, since patient health will be impacted!

[toomuchbaloney]

I don't work in LTC.

However, if you believe that the practice of this coworker is endangering the POC or health outcomes of your shared patients you are obligated to advocate on their behalf. That suggests to me that, if I was in your shoes, I would have to find a way to address this with the other RN in a professional and constructive way.

Good luck.

[EmpathyInAction]

I had not yet addressed the other RN. This is my first time encountering a situation like this, which is why I was seeking advice.

[amoLucia]

Regardless of what you do re her overall med admin issues, PLEASE, be super cautious about your narc count. You know that once you accept the keys, it'll be your butt under the bus if the count is wrong somewhere. Other nurse will plead dumb.

[jadelpn, LPN, EMT-B]

When you take over a med cart, it then becomes your responsibility.

Because you now know that there may or may not be random meds left in the cart, I would look in each drawer and have off-going nurse waste them, with the other nurse on her shift (providing there is one). I would not put my signature on random meds that I have no clue. Also, it would concern me that narc counts are off and she is "changing" them, which again, I wouldn't want my signature any part of.

What is the policy when narc count is off?

You are sorta stuck, and I understand your concerns. I would be concerned about the med cups with random meds rolling around, but moreso with the narcs, that you could be held accountable for. And the "don't tell on her" mentality is all fine, well and good until you are blamed for another nurse's poor practice.

Ask the nurse directly to be sure that there are no loose meds before you take over the cart. "I am uncomfortable with the amount of unlabeled, random full med cups that are left in the cart. Before I take it over, you need to resolve this issue, and let me know exactly who did not get their meds, in case I run into issues later" "I can not sign off on an incorrect narc count"

And if the narc count is off, be sure you address that per the policy. If you are noticing trends in residents that are, for instance, up all night when they were to be having a sleep aid, or behavior changes due to not receiving their scheduled narcs, then it is something you need to discuss with your manager.

How other nurse's choose to practice is on them, but don't let it affect your practice. And 99.9% of nurses who have been working for more than a week absolutely KNOW that this is poor practice. And know that YOU could get in hot water for their "shortcuts". And are assuming that you will play the "don't ask/don't tell" game. And that with you being new to the facility, the nurse in question can throw you under the bus....especially when the narc count is altered, and your signature is on it, and next thing you know, you are accused of diverting....or participating in records falsification...or 50 other things that a surveyor can discover, that the state can discover, or the family can discover. Duty to act. Because everyone is hush--hush until the surprise survey...and then it is "well WHY did EmpathyInAction take OVER a med cart that was messed up? Hmmmmm? If she would have gone to the charge nurse, this wouldn't have continued...." Selective amnesia at its finest...

[BrandonLPN, LPN]

I had not yet addressed the other RN. This is my first time encountering a situation like this, which is why I was seeking advice.

My advice would be to address it with her the next time you see her. Discreetly say "Last time I followed you, you left a couple cups of pills in the med cart". If she has any grace at all, she will be grateful to you for telling her. Hopefully this will prompt her to be more careful in the future, and it will all become a non-issue. If you continue to find meds in the cart like this even after addressing it with her, well, then you'll have no choice but to bring the issue to your immediate supervisor. It's not safe for the residents who aren't being medicated, and it's not fair for you to be left with such messes to have to clean up.

And, to be brutally honest, if this is something this nurse is doing on any sort of regular basis, she clearly needs some form of re-education and/or should not be a nurse as her practice is dangerous. Any nurse who passes large volumes of medications will, at some point, have a scenario where they leave a cup of pills in the cart or at the bedside by mistake. It will happen. But for this to be happening repeatedly is totally unacceptable.

[EmpathyInAction]

Jadelpn I think you really summed up some of my thoughts better than I did. It really sounds like you understand my very real concerns.

As for the narcotics count being off, it happens like this: When we do the narc count, she is reading the logs while I am counting. She gives a number and I say it's off by one and she goes "oh ya, I did give him/her one" and she'll sign it out right then, to my guess likely with the wrong time. Who knows if she did actually give the narc considering. Sometimes it's multiple narc for multiple patients during a count. The whole thing makes me very uneasy. I'm especially paranoid with narcotics and always double/triple check things before I punch them from the blister pack, then I make sure the patient takes it before I document it in the eMAR. Her lack of concern for proper dealing with narcs and laze fare attitude "oh, oops, he he" is distressing. That's all above and beyond my general concern for patient safety with unlabeled meds/ med cups/ meds not being administered.

I understand the point made of talking with her directly, but am glad to see I'm not alone in seeing a serious issue with her practices.

[Seaofclouds, BSN, RN]

Honestly, the way you describe how your narc count goes would concern me for a diversion, especially if this happens regularly. You really should report this to your nursing supervisor. They can do the full investigation to see if she is signing off that she gave the meds and speak with the residents to see if they remember getting the meds.