How safe are these practices? Help, new grad RN in LTC

MN-Nurse, ASN, RN · May 30, 2012

Hi,
thank you for reading, I will try to make this as short as possible.
1) started my noc shift; pm shift nurse told me about this non-compliant pt about her blood sugar being 400, and that she administered 10 units of regular insulin. husband's patient walks up and asks me to check on her because she is feeling sick, pm nurse still on the clock. pt has low BP with high pulse pressure, i think of checking her blood sugar, it's 591!! i thought i was gonna collapse. the pm nurse was supposed to call MD if blood sugar is more than 400, but she didn't. also, within 3 hours, her BS was down to 300, in the morning it was already 130. did she lie about only administering 10 units? was I supposed to call MD? what if the pt died on my shift because i believed that her bs was under control? this pt has a hx of liver disease, chronic renal (dialysis) and DM. this high blood sugar was after she went out with a pass and went to a buffet. isn't she liability???
2) that nurse also had an unwitnessed fall and never started her neuro checks; i did and charted it, i couldn't call MD or ask for X-rays at night time...
3) LVN's at night do their hair, nails and make-up at the nurse's station. not only highly unprofessional, but they are getting paid to do something else. one of them hangs out in anempty patient's room the whole night shift while I am STILL orienting and could be learning from someone for a change!!! the whole management is crazy over state coming in right now! idk what to do!

1. Forget what the other nurse did; it looks like you had a glucose of 591 and you didn't call the MD?? That's all on you regardless of what happened on the previous shift. Diabetic patients often have labile blood sugars, you just deal with it. It does not matter what the previous RN did or what the patient ate - YOU have to do your job.

2. Again, do your job as best you can.

3. Sounds like your average LTC. Do your job the best you can while you look for somewhere else to work.

Good luck.

Linka · May 30, 2012

Thank you for the reply. i guess my reasoning for not calling was i really thought i didn't have what to say to the MD because since the nurse lied to me that the BS was 400, then God knows how much insulin she had really given and with MD's orders carried out I could've made her really hypoglycemic. this patient does go out on passes and gets back with her sugar in her 400's all the time. I monitored her every 15 minutes....you are right though, the chart does say to call him if the BS is more than 400!!

Double-Helix, BSN, RN · May 30, 2012

1. What did you do when the patient's blood sugar as 591? Did you give any insulin? It's unreasonable and unprofessional to just assume the nurse lied about the blood sugar and how much insulin she gave. What possible reason does she have to lie about that? If the patient had just come back from a buffet then maybe her blood sugar was 400 when she returned, but was still rising from the meal. Or she brought dessert back with her and continued to eat it. If the blood sugar was 400, and not over, then the nurse didn't have to call the MD, per the order. YOU did have to call the MD, and failed to do so, and are now making excuses for not following through with your responsibilities (the exact same thing you are accusing the other nurse of in this post).

When you have to call the doctor about a problem with a patient, you might never be able to verify with 100% accuracy what happened the previous shift. If you call the doctor about a blood pressure of 170/95 and the doctor asks "Did the patient get his metoprolol this evening?" you might not know for sure that he did, but you go by what is in the documentation. You don't skip calling the MD about a sky-high blood sugar because you don't trust the nurse you got report from. That's unsafe practice.

If you didn't do anything to treat the BS of 591 and it corrected, then the patient had obviously received some insulin. Obviously none of us can tell you how much the patient received or whether the nurse lied. (Again, why would she do that?) It sounds like she has labile blood sugars.

You're the patient's nurse- not the patient's mother. She's a resident at a nursing home, not a prisoner. If she chooses to go to buffets and eat like crazy and shoot her blood sugar up, then that's her choice and her right. So no, she isn't a "liability" because the facility isn't liable for her behavior. If she were going to die from a blood sugar problem, there would be signs and symptoms. You, as the nurse, would recognize the symptoms, assess the patient, and correct the problem, or call for assistance from EMS or the MD.

2. Should she have started neuro checks? Yes. Have you ever gotten behind on your shift or forgotten to do something extra? I'm willing to bet you are have. It's good that you started the neuro check (and x-rays aren't always indicated in a fall), but I don't suggest that you start nitpicking every little thing that your co-workers forget to do.

3. This may not be the most professional behavior, but it isn't inherently unsafe. YOU are the only person whose behavior you can control. Do your job as best you can. Document everything thoroughly. When a problem comes up on your shift- you handle it appropriately, regardless of which shift "started it." If you're that concerned about the practices of this facility, I suggest you start looking for other employment. Preferably not a LTC, because all that you described seems pretty standard for most LTC facilities.

OnlybyHisgraceRN, ASN, RN · May 31, 2012

I agree with the above. I'm more concened about what you did not do. Never assume someone else did something or did not do something. Remember, nursing is 24/7. Never be afraid to call the MD at night for an x-ray or anything for that matter, as long as it is important you are okay.

I'm sorry you experienced this. LTC can be a very stressful environment with staff that have a " I don't care " attitude.

My advice is to keep looking for another job that will be more of a great learning environment. Learn from your mistake and move on.

Cat_RN, ASN, BSN, RN · May 31, 2012

1. I would have called the MD and informed of the 591 and the time other nurse gave the insulin. Also- I'd let him know the pt was non-compliant with her diet.

2. Document the non-compliance and that MD was made aware.

3. You can ALWAYS call MD at any hour. It's a 24 hour nursing facility. Cover yourself and protect your patient! If you think something's broken- it can't wait until morning. I've never been yelled at for calling at night for a real reason like this. (Plus, who cares if they yell- they don't really KNOW you and they get into this business knowing it involves late night phone calls

4. Is the DON aware of the business going on at the nurse's station at night? That would NEVER fly in my LTC and you shouldn't have to work amongst such slackers. Horrible! We are wayyy too busy even at night to be hiding in rooms or thinking of doing out hair at the NS!

5. Even though the other nurse failed to initiate neuro checks, you're responsible for the pt now. You should have initated them. Two wrongs don't make a right. You are responsible for evaulating your patients and to keep an eye on the ones with potential for a change in condition. Post fall assessments are integral and neuro's are included to monitor for a change in condition. Of course, let your unit manager know in the morning that they were initiated late so she can follow up with the prior nurse and understand what happened. CYA, CYA, CYA!

I worked nights for 3 years in a rehab/LTC. I've followed more than one nurse who were slack on documentation and who have had falls and did not notify MD. When the pt begins to c/o pain on my shift, I have to call the MD in the middle of the night to request an Xray. There have been two instances where fractures have actually been the result of these falls and I'm SO glad I called. Don't let it wait until morning when it shouldn't. We night shifters are nurse's too! Not everything needs to be passed on to day shift :) Trust me, as a day shifter now, we appreciate it!

kids · May 31, 2012

Hi,
thank you for reading, I will try to make this as short as possible.
1) started my noc shift; pm shift nurse told me about this non-compliant pt about her blood sugar being 400, and that she administered 10 units of regular insulin. husband's patient walks up and asks me to check on her because she is feeling sick, pm nurse still on the clock. pt has low BP with high pulse pressure, i think of checking her blood sugar, it's 591!! i thought i was gonna collapse. the pm nurse was supposed to call MD if blood sugar is more than 400, but she didn't. also, within 3 hours, her BS was down to 300, in the morning it was already 130. did she lie about only administering 10 units? was I supposed to call MD? what if the pt died on my shift because i believed that her bs was under control? this pt has a hx of liver disease, chronic renal (dialysis) and DM. this high blood sugar was after she went out with a pass and went to a buffet. isn't she liability???
2) that nurse also had an unwitnessed fall and never started her neuro checks; i did and charted it, i couldn't call MD or ask for X-rays at night time...
3) LVN's at night do their hair, nails and make-up at the nurse's station. not only highly unprofessional, but they are getting paid to do something else. one of them hangs out in anempty patient's room the whole night shift while I am STILL orienting and could be learning from someone for a change!!! the whole management is crazy over state coming in right now! idk what to do!

In situation 1 there is nothing wrong with the nurse not calling. The patients blood sugar was 400 not greater than 400. The patient very likely got her 10 units and had eatten something just before the blood sugar check or ate more after the insulin was given.

Yes, you probably should have called the doctor not just because her CBG was 591 but also because she was feeling unwell and had an (I assume) abnormal BP.

A liability to who? She's a competent adult who is choosing to be non-compliant. As long as she's not being enabled in her non-compliance by the facility (staff giving her foods and fluids outside her restrictions) and has been throughly educated on the risks she's only a liability to her self. She's a grown up, grown ups get to choose to kill themselves slowly.

2) It was a screw up that neuro checks weren't started. You most certainly can call a doctor in the middle of the night for orders if the patient condition warrants it.

3) Not ok at all, report it to management but expect that you're either ignored of experience fallout from the staff you reported.

morte, LPN, LVN · May 31, 2012

If your glucometers have a memory function check back through.....also make sure that your technique for checking is correct.

Anna Flaxis, BSN, RN · May 31, 2012

1) No, the PM nurse did not need to call the MD. The blood sugar was 400, not GREATER than 400, which is what you say the order says. When you discovered it was 591, YOU should have called the MD. It does not matter that the PM nurse is still on the clock. Once you have taken report, you have assumed care and are responsible for patient care from that time forward. It is very possible that 10 units of regular would have corrected her blood sugar overnight. She sounds like a brittle diabetic, which is a diabetic whose blood sugars are very labile. With her comorbidities, this makes sense.

2) It depends on how far into the previous nurse's shift the fall occurred. If it happened at the beginning, then yes, I would absolutely have expected her to start neuro checks. But if it happened toward the end, when she was trying to play catch-up and tie up loose ends, then I can see how it could have gotten away from her. I'm not excusing it, neuro checks should have been started no matter what, but my understanding is that the typical LTC work load is so heavy, that you have to really prioritize. If there was no indication that the resident hit her head when she fell (no head pain, no contusions, no lacerations) and the resident seemed okay, I can see how the other nurse would have deferred the neuro checks until she got caught up. Were x-rays indicated? Was she complaining of any hip pain or any new pain elsewhere in her body? Did you assess her CMS and ROM? What were your findings? In the event that your assessment suggests a possible fracture or head injury, it doesn't matter that it's night time, it doesn't matter what the other nurse did or didn't do, you still call the MD. If you cannot get hold of the MD, then it would be reasonable to have her transported to the ED.

3) Not cool, but in my opinion, you should worry about yourself and do your job to the best of your ability rather than focusing on what everyone else is doing.

Linka · Jun 1, 2012

first of all, thank you all for taking your time and writing all of this, this really helps me understand my responsibilities more. I was not trying to push the blame on the other nurse, but it was scary to deal with everything. i thought that in a perfect world, the older nurse wouldn't leave such a load on a person still orienting; it did make me frustrated and I realize that real life is different. and honestly, i didn't even realize she never called the MD.

She gave me report of blood sugar of 400, but I later discovered that on the 24-hr nursing report she wrote down "in the 500's"....I should've been more precise. I discovered the 24-hr nursing report after I decided to check her blood sugar. I "assumed" she lied because the other nurse that was orienting me told me that I shouldn't trust the other nurse, that this wasn't the first time she did that etc. she also told me to wait it out and see what happens, and so I, zero critical thinking, did.the blood sugar went down to 300 within the next two-three hours I believe.

tyvin, BSN, RN · Jun 1, 2012

You're going to find a lot of that in some LTCs...with the fall; don't wait. If you do an exam and determine there may be a break of course you call the MD and send the resident out. Don't wait... Eve and Noc have a responsibiltiy to inform the MDs (or their on-call) when emergent things happen no matter what time it is.

With the BS...maybe that's her history and the parameters need to be changed.

Good luck to you.

jadelpn, LPN, EMT-B · Jun 1, 2012

While you are orienting and beyond, one thing that should be your priority--

Think about your practice, your patients, your interventions. Do not get caught up in "well this nurse told me that this nurse does such and so...." LTC is not easy, and the less you get involved in the gossip and bad mouthing the better. If there are people at the nurse's station that are doing hair or whatever....and you need to delegate something to them, delegate. Should they not comply, then that is another thing entirely, and can be disciplined. You can look to report to get a good backround on a patient's day. It is not an indication on how the patient is doing at present. You need to make your own decisions on your assessments based on the MD orders. And in this case, YOU assessed a patient that had a FBS that was indicative of a call to the doctor. You did not do so, even though along with that there was a change in vitals. That is some alarming changes that would indicate that the priority be on calling MD, and perhaps sending patient out to the ED for follow-up. NOT concentrating on "well this nurse lied, the girls are doing hair, nurse one said that nurse 2 is a liar, and I need to do neuro checks......" Most critical first. Always.