Nurses not following Protocols

  1. I am a RN in LTC. It has been well over a year now that nurses are not following important protocols. The new nurses in the last year are not taught to follow protocol or to document correctly, then they orientate new nurses without teaching them protocols, then no one knows what they are doing. Recently I have reviewed approx 30 charts for the MDS, and found many problems with documentation. Here is just a couple of protocols they do not follow:

    1. Skin Protocol & Protocol for Pressure Ulcers - many nurses document like this: open area on buttocks, duoderm applied, check daily for placement or open area 1cm x 1cm, duoderm applied, check daily. Thats all thats done. My main gripe is Protocol for pressure ulcers, no prog note, skin sheet not started, order for labs, orders for zinc and vit.C not obtained by MD, referral to dietician not made, care plans not updated, no skin assessments to follow, pressure relieving devices not initiated. This is a constant problem, no inservices to correct this problem.

    2. Fall Incident Reports - the nurses do not fill out the incident reports correctly, and the prog notes are extremely vague. Reading the prog notes, I have no idea when the fall occured, how they fell, no vitals, no intervention to prevent fall and care plan not initiated or updated.

    I am not in the position to make corrections with the nurses. The DNS is and is not doing so. Any thoughts on this?
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    About kasi

    Joined: Jun '03; Posts: 9
    RN

    12 Comments

  3. by   santhony44
    I would document my concerns, present them to the DNS, and keep personal copies of the documentation, the meeting with the DNS, and the outcome. If that doesn't get anywhere, try talking with the administrator.

    Can you offer to train or inservice the nurses on the correct protocols and documentation?

    If you stay on in that facility, I would do the same with every single similar instance you find in the future. If they are not willing to correct such a problem, then you may want to rethink your employment there.
  4. by   TrudyRN
    I feel your pain. My DNS is sometimes quite unwilling to take what I think is necessary action, also. Mostly, I just move on, keep quiet, let her be the boss.

    I don't know if you have tried going over her head to the Administrator but that is one possibility, albeit a possibly inadvisable one. You might get into lots of trouble, you might find the same lack of receptivity there. Going to Corporate or your facility's attorneys - same thing. It could go very well or it could backfire.

    There is the choice of going outside the facility and reporting this to the authorities who oversee and accredit your facility, those who license it. I guess that would be CMS (Medicare), maybe some state agency, maybe your state legislators.

    Or you could try informing the newspaper, TV, radio stations, and senior citizen advocacy groups.

    They're all pretty darned scary and there's no guarantee you'd still have a job or be able to effect the change you seek to effect.

    I guess I'd need to really think this through, figure out if I would be willing to risk my job and maybe wind up having to sue the place - or try to (wrongful termination, retaliation for whistleblowing, etc.).

    You might want to get some legal advice from a private attorney before doing anything in order to avoid being fired, charged with slander or libel, having false accusations made about you to the state Board of Nursing, etc.

    I think you need to ask yourself how vital it is for protocols to be followed, how the patients are faring in light of the protocols not being followed, and whether you might be able to quietly, informally teach the protocols to the staff. Or can you get them instituted on your own, by doing the work yourself that the staff should be doing. And if you do that, hopefully the staff would pick up on it.

    You could post the protocols prominently around the nurses' station, coat room, locker room, toilet, wherever they'd be most likely to be seen - maybe the smoking area, LOL.

    One other thought - do you know why your DNS is unwilling to take action? Maybe understanding her reluctance would help you figure out a solution. With my own boss, it is due, I think, to the fact that she can't stand having anyone else come up with good ideas. Yep, megalomaniacal, power hungry madness. In all its splendor. At least, she doesn't take kindly to suggestions from me or from at least 1 other person I know. She "hears" only some of the managers - the inner clique. It's really frustrating. Sometimes I do things on my own, quietly, unobtrusively, thinking of the patients' welfare, keeping my own counsel, with God my everpresent Friend and Strength. And I think about the fact that I will soon retire and not have to deal with her for much longer, LOL.

    I don't envy you, I truly wish you good luck, and I hope you find a workable solution.
    Last edit by TrudyRN on Oct 22, '06
  5. by   jetscreamer101
    I also encounter this on a routine basis. Falls inadequately charted, no follow through on monitoring vitals, open areas without treatments or protocals followed, no charting with condition changes, work left undone, I could go on. I've tried 1:1 with some of the nurses. It helps for s short time, then the behavior resumes. Talking to DNS is like talking to a wall. And she's no better. There was a specific resident behavior that should have been charted in detail, and the nurse was told to not document it at all! I know I'll eventually get in trouble over this because I followed her charting with an entry specifically refering to the incident that wasn't charted.
  6. by   banditrn
    I know exactly what you're talking about. I received 3 days orientation to my current job, plus, I work nites, and there is no one around to ask.

    When most things have come up, I've followed what I would do at the hospital. Because anyone you ask doesn't seem to be able to give a straight answer. The DON is not usually available, won't return phone calls, and it's one of the reasons I'm getting out of there.
  7. by   Daytonite
    kasi. . .you know you can't make anyone do anything. In the end, we can all only be responsible for our own actions and what we document. All you can do is shake your head and wonder what these people would do if they ever were called on the carpet about their care and documentation. At least don't let yourself get into that position. Just do what you know is the right way when it comes to following policies, procedures and care.

    There are ways to influence their behavior when you have the authority. Sounds like you might be ready to take the step up into management and supervision. That is the only way you might have SOME ability to do something about the omissions you are seeing. It won't guarantee that they will still get done, however. Are you game?
  8. by   CapeCodMermaid
    Wow-this is the 4 post I've read tonight where DNS bashing seems to be most of what is going on. I AM the DNS and I have the same problems as all y'all. I've clearly spelled out my expectations and have given all the nurses copies of the most important protocols. They have been told and the repeat offenders have been warned. They get one Get Out of Jail Free card and that's it. They don't do what they are supposed to do and they get written up. I have been called all sorts of names but the nurses are finally starting to step up and to what they are supposed to do.
    I am oncall 24 hours a day 7 days a week and always call back. I make rounds on the floors at least twice if not 3 times a day. I toilet people, I take off orders, I sit with people who are going to die. Do the nurses do any of MY work???? nope....they complain about management. Do they know that I've spent the last 2 hours asking for pay raises for THEM??? nope. They (and apparently most of you) think the DNS has it made. Let me tell you...if YOU screw up, I could get sued. It's that simple.
    .....rant over. thank you.
  9. by   kasi
    Hello, thanks everyone for your replies. Our DNS has been there 4 years. He has been there long enough to have solved some of these problems. I don't think the DNS has it made. He has a tough job, but needs to work on priorities such as so many of the nurses not complying with the guidelines. As for inservices and training, I would love to educate the staff! But, they won't allow it because of the budget! They just expect nurses to learn during their shift. As for the residents, so far no one has suffered from protocols not followed. Thank goodness!
  10. by   rehab nurse
    well, i'm just an LPN, but i've been anurse for 11 years now.

    can we all get together and run our own nursinghome? cause what y'all are describing is my former employer. nurses in the "clique" get their skills (or lack thereof) acknowledged with parties, memo's of their "greatness" posted, etc. barf. where's the smilie with the...you know...lol

    no one charts, and if they DO chart, it's stuff that doesn't need to be. falls, incidents, people with chest pain or any other pain not charted on. the list goes on and on. ad nauseum. it's ridiculous. the care is terrible, the decent hardworking nurses are all leaving (have left for greener pastures) and now it's all agency. the DON does nothing but dote on her prized nurses. the lack of care to those poor residents is just astounding and sickening. new management took over a few months ago, and now all of the nurses who've been there for years (some decades!) are GONE. the medical staff is crying for some familiar faces, the residents are scared (ive been back to see). it's sad really.

    can we all get together and run a nursing home the proper way? where policy is followed and the residents get proper care??? please? maybe if we all get together, one place will be run the right way.
    :spin:
  11. by   banditrn
    Quote from CapeCodMermaid
    Wow-this is the 4 post I've read tonight where DNS bashing seems to be most of what is going on. I AM the DNS and I have the same problems as all y'all. I've clearly spelled out my expectations and have given all the nurses copies of the most important protocols. They have been told and the repeat offenders have been warned. They get one Get Out of Jail Free card and that's it. They don't do what they are supposed to do and they get written up. I have been called all sorts of names but the nurses are finally starting to step up and to what they are supposed to do.
    I am oncall 24 hours a day 7 days a week and always call back. I make rounds on the floors at least twice if not 3 times a day. I toilet people, I take off orders, I sit with people who are going to die. Do the nurses do any of MY work???? nope....they complain about management. Do they know that I've spent the last 2 hours asking for pay raises for THEM??? nope. They (and apparently most of you) think the DNS has it made. Let me tell you...if YOU screw up, I could get sued. It's that simple.
    .....rant over. thank you.
    Capecod - I understand what you're saying - and you seem to be a cut above. I've had some very professional, wonderful DON's and supervisors over the years, so I know what they look like. The one I have now is NOT in that category!!

    You've read my posts before - this gal does none of the things you talk about - she's seldom even there every day.

    A leader leads by example. No one is saying that every DON is bad, just like not all nurses are good.
  12. by   Lovin' my job!
    I started a new casual position in the second LTC facility Ive ever worked in in 4 yrs. Boy, it sure is different from what I'm used to! One of the first things I did on my first day of orientation was go through the policy/procedure book. 2 nurses must count narcotics between shifts...ya, right...they must have another facitlities policy book cause they don't do that. I spoke with the assisstant DOC re this (cause I came across an error) who said "oh, well, what I would do is if you work a stretch of 5 days say, count narcs on your first day and then your fifth day." Ummm ya. ok. Needless to say I was speechless. Her other great line for the day was "well, you know how it goes, 90% of the people do what they will, the other 10% follow the rules" and she walked away. Ya, there's all the positive attitude I was looking for in management! It's sad, knowing that after 4 yrs experience I've learned to assume the person before me DID NOT follow policy/procedure. That way my butts covered. I always count narcs before I start. Just because it's signed - doesn't mean its done. etc. Too bad. My biggest pet peeve is all those forms/documents...only half done! Not signed, dated, incomplete. God, why bother if youre not gonna do it properly!!
  13. by   brendamyheart
    Quote from CapeCodMermaid
    Wow-this is the 4 post I've read tonight where DNS bashing seems to be most of what is going on. I AM the DNS and I have the same problems as all y'all. I've clearly spelled out my expectations and have given all the nurses copies of the most important protocols. They have been told and the repeat offenders have been warned. They get one Get Out of Jail Free card and that's it. They don't do what they are supposed to do and they get written up. I have been called all sorts of names but the nurses are finally starting to step up and to what they are supposed to do.
    I am oncall 24 hours a day 7 days a week and always call back. I make rounds on the floors at least twice if not 3 times a day. I toilet people, I take off orders, I sit with people who are going to die. Do the nurses do any of MY work???? nope....they complain about management. Do they know that I've spent the last 2 hours asking for pay raises for THEM??? nope. They (and apparently most of you) think the DNS has it made. Let me tell you...if YOU screw up, I could get sued. It's that simple.
    .....rant over. thank you.
    Sounds like you are a good DSN. I think they we refering to their DSN'S who do not take pride in their work as you do.
  14. by   Simplepleasures
    If this is happening and you know it, then why dont you or someone in authority have a mandatory inservice addressing these concerns?Responsibility does not stop with the floor nurses.

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