I am starting LPN school next week, and as a CNA, I was wondering about some of the things that I have seen nurses do in caring for residents, and curious if they were considered "acceptable." I have also heard some "hearsay" stories from other CNAs and LPNs about some of the things they have witnessed. I just wanted to list 3 of these behaviors, and get feedback about whether these items were common, OK, or justified, since I would like to avoid tasks that would harm people.
1. Dropping meds on the floor, and picking them up and giving them to residents/patients anyway. I know that this should not be acceptable at all, and I would always just get myself another pill if I dropped one. However, when I asked about this, I was told that the nurse would get "in trouble" if they just got another pill, especially a narcotic, because admin would wonder if the nurse kept the dropped pill for herself. This action was also justified because the resident was only prescribed a certain number of pills, and that they could never be wasted, lest it would cost the patient more money for meds to replace dropped pills. Is this practice common?
2. What about nurses who hide meds in food to give to patients, and the patients don't know about it, because the patients would refuse the medicine otherwise? I would think this may not work, one reason being that if the patient doesn't eat all of her food, or doesn't drink the drink with the med in it, she wouldn't get the full dose of the med that she needs. Plus, I thought that people had the right to refuse medicine. Is sneaking medicine in food OK? Also, what if the patient or resident has to be fed his meals, and a family member or CNA feeds the resident with the food with the meds in it? Isn't that considered passing meds by a nonlicensed person?
3. What about borrowing prescription meds in "emergency" situations? I am told that this may happen because of some error on refilling a prescription, and not being able to get the refill in time for the dose, so it's okay to get the pill from another patient who has the same script, since it would hurt a patient more not to get her pill on time, than it would hurt the patient (the one whose pill is getting borrowed) who may not need it right away. (This seems in violation of #1 above, where the nurse claims she would get in trouble if a pill is unaccounted for. )
So if there's a doctor's order, and the medical power of attorney approves, then it's okay to hide medicine in food? I understand that in a dementia unit, the residents may not fully understand why they need the meds, so they may not comprehend what could happen if they refuse. However, I am wondering if the state inspectors who come to nursing homes would approve of a nurse sneaking medicine into food, even if there is a doctor's order. I was taught in CNA class that even dementia residents have the same resident's rights as other people, so if they, say, refused a shower, or refused a treatment, we couldn't force them to take a shower or treatment "for their own good."
no, i'm sure the state would never approve of these tactics.
the state would expect you to attempt giving meds a few different times and if to no avail, notify md...
if a pt is on a b/p/cardiac/throid medd it would be in their interest to be given their meds in food if their doctor and rp have agreed to this
if a doctor writes an order than it is legal and i can't believe that state would object- i have seen orders that said 'give in apple sauce' because many meds will dissolve in applesauce easier
in many ltc facilities the meds come on a punch out card and there is a sticker that you send to pharmacy a few days before the last pill is given, if you run out on a day shift they will come and deliver that med but if you are giving an hs or night med the pharmist will more often than not tell you to borrow if it is not a controlled drug
floors are really nasty
as for hospital vs ltc i don't believe that the care that is given is better one place or another, i have seen good/bad nurses in both places
Okay, so what about the dementia pt with a sky high BP who won't take his meds? You just let him stroke out and die, and then tell his family, "well, he wouldn't take his pills." That's a lawsuit waiting to happen. And say you call the doc and tell him that the pt won't take his pills. What do you think he's going to tell you?
Just playing devil's advocate here. And I am in NO WAY saying it's ok to hide meds for an A&O pt!!!
I am still a CNA, not a nurse, and I am going to LPN school this month. I am asking about these possible scenarios because when I become a nurse, I want to know what the proper procedures are for handling meds, such as if they fall on the floor, or if it's OK to sneak pills into food.
From what I was taught, residents or patients have the right to refuse meds, meals, baths, etc., and there was no exception for people with dementia. Also, I was taught that if they refuse after a few times, and despite being told the risks, then the nurse was to document the refusal and notify the doctor.
However, I understand why nurses would try to sneak life-saving meds into food if a resident, especially one with dementia, refuses to take it. Moreover, I see the dilemma you mentioned. There is a contradiction between what us healthcare workers are taught (all residents have the right to refuse any treatments or meds), and real-life (however, you will be at fault if a resident doesn't take the life-saving BP meds). If the state comes in and sees a nurse sneaking meds to a resident in food, will they accept the explanation that the med is a life-saving BP med, and that the resident won't take the med, so this is the only way to get it to him or her? What does the state, or nursing body, expect nurses to do in situations like this? Sneak the med in, violate the resident's rights, or note the refusal, but the patient suffers as a result? I am confused, and I'm not a nurse yet!
I'm an RN student and a tech on the med surg unit and I also have been witness to some "bad habits" that nurses get into... (Injections with no gloves, reinserting foleys after they've been in the lady parts, ect.) I don't say anything I just note it so that I won't repeat the mistake.
1. If you get a second nurse to waste the med with you can get a new med.... I surely wouldn't eat off the floor and neither will my patients.
2. Patients have the right to refuse against medical advice... It is based on the priciple of autonomy... They can only refuse after the treatment and the consequences of not recieving treatment have been explained... Medicine can be put in apple sauce or pudding so that it will go down easier or if the patient can't swallow pills... But giving medicine without tell the patient is wrong. It sounds like you work in a nursing home and many of those patients are unable to make their own medical decisions any more and that may be why their meds have to be hidden.
3. I see no problem with this one as long as it's definately the right med.... Although I work in the hospital setting and it may be different in the nursing home... Usually pharmacy has every patients' home meds and any other med they are ordered in the hospital.
1. Reusing a contaminated med is nasty and not necessary. The contamination can definitely cause more problems if it happens in a LTC environment.
2. Many residents in LTC can't make their own decisions. Many times they will refuse meds but not refuse pudding or ice cream. This is a big problem with dementia residents. It's like a dog... many dogs won't take a heartworm med, but if you but it in a scoop of doggie ice cream they swallow it right up. (Not comparing residents to dogs...)
3. 'Borrowing' meds is technically misappropriation which is illegal. I have brought up this point with nurses I work with. Many are aware that if they were caught they would be in serious trouble but as of yet, no one has any ideas how to avoid the issue. Pharmacies don't deliver on demand. There is only the 2 hour window to give the med and usually if meds are missing it was due to another nurse not ordering the new meds or the pharmacy forgetting to deliver it. What can they do? It seems to be an accepted practice because in most cases the resident getting the med is more important than stopping the misappropriation. It is definitely something that needs to be worked on. Would be nice if LTC facilities had extra stashes of important medicines. They wouldn't have to be large, maybe a couple of bubble packs of each med with multiple dosages. Enough to have in an emergency but not enough to make having it costly...
no, i'm sure the state would never approve of these tactics.
the state would expect you to attempt giving meds a few different times and if to no avail, notify md...
and, write darned thorough nsg notes.
and, continue to monitor pt.
leslie
I don't believe the state ever had an issue with allowing hidden meds with a doctor's order and signed consent from medical POA since this is referring to people who do not make their own medical decisions anyway. They aren't able to give consent for anything, including the decision to hospitalize, go to doctor's appointments, have procedures or treatments for medical conditions, and even to take medications. Sometimes denying meds because "the patient refuses" is the equivalent of euthenasia. There must be a way to make the decision for the patient when they are incapacitated to a point where they cannot make these decisions themselves. This is where a written doctor's order and written consent form from the person's guardian or power of attorney come in.
none of the practices you listed are acceptable. on that note, mama always said "what goes around comes around" those nurses will be patients one day too...hope their pills don't fall on the floor, etc...
I don't believe the state ever had an issue with allowing hidden meds with a doctor's order and signed consent from medical POA since this is referring to people who do not make their own medical decisions anyway. They aren't able to give consent for anything, including the decision to hospitalize, go to doctor's appointments, have procedures or treatments for medical conditions, and even to take medications. Sometimes denying meds because "the patient refuses" is the equivalent of euthenasia. There must be a way to make the decision for the patient when they are incapacitated to a point where they cannot make these decisions themselves. This is where a written doctor's order and written consent form from the person's guardian or power of attorney come in.
let me clarify:
this practice is acceptable w/poa and md consent.
but in the absence of these, it is considered unethical.
I did clinicals at a LTC and they had a drawer full of meds. Some had the pt's name on it and some didn't. The CMA would look at the MAR and grab the med paying little attention to who it belonged to. When I worked at a join I noticed CMA's doing the samething. Is it right? The way the systems where set up in these two facilities there was no way around it.
However, I understand why nurses would try to sneak life-saving meds into food if a resident, especially one with dementia, refuses to take it. Moreover, I see the dilemma you mentioned. There is a contradiction between what us healthcare workers are taught (all residents have the right to refuse any treatments or meds), and real-life (however, you will be at fault if a resident doesn't take the life-saving BP meds). If the state comes in and sees a nurse sneaking meds to a resident in food, will they accept the explanation that the med is a life-saving BP med, and that the resident won't take the med, so this is the only way to get it to him or her? What does the state, or nursing body, expect nurses to do in situations like this? Sneak the med in, violate the resident's rights, or note the refusal, but the patient suffers as a result? I am confused, and I'm not a nurse yet!
I guess it's because I don't work long term care, but here's the thing. With the way you are describing it, I am picturing some old black and white movie with a villian who has a top hat and a handlebar mustache tying a resident to the train tracks and making them eat pudding with all kinds of pills sticking out of it. It's never been that big of a deal for me, I guess. Usually I just crush the med up and put it in some applesauce. I say, "here, take a bite of this, it has your medicine in it". They usually take the bite. Sometimes they won't, and I have to coax, but I've not really had a problem getting them to take it. I think I just annoy them so bad that when I say, "if you just take it, I'll stop bothering you", they do it just to shut me up! :chuckle
I can understand if you work LTC and you are with these pts day in and day out, but then I would think that their POA would know about what is going on and be fine with it - otherwise, why would they be there in the first place? And then you would think that the nurses know the pts well enough to know what is necessary to get the pt to take the meds they need. If that means they have to sneak their BP meds into a bite of applesauce, then so be it.
Here's my thought... LPNs and RNs both go to school and hopefully learn nursing judgement. I hope that they utilize it.
In nursing - some situations are black and white. But many aren't.
I've had patients take pills that have rolled into their beds... when I could have wasted them and brought them fresh.
I've hidden pills lots of times (but I do work with kids and typically it is by the request - actually insistence - of the parents. I'm one of those tell-it-like-it-is nurses.)
And in the hospital - pharmacy can sometimes take longer than you are able to wait. And the lesser of two evils is to use someone else's un-needed meds and then nuance the charges appropriately.
I know for me - anytime I 'fudge' the exact rules, I'm on hyper-alert. I run it by my BIGGEST resource on the floor - my coworkers. I triple-quadruple check.
But pt. care comes before procedure sometimes - and I trust my judgement and will stand by it.
An outside observer usually has no idea all the things I'm weighing in my mind when I make decisions... which is why I try and give my coworkers the same benefit of the doubt when I see them do something that looks a bit odd. (I'll still ask though!)
If I have a demented, combative resident who needs that Haldol or other psych med it goes into ice cream instead of my trying to get an order for IM so that I have to wait for it and then hold him/her screaming and kickling and biting while I inject it.
So if there's a doctor's order, and the medical power of attorney approves, then it's okay to hide medicine in food? I understand that in a dementia unit, the residents may not fully understand why they need the meds, so they may not comprehend what could happen if they refuse. However, I am wondering if the state inspectors who come to nursing homes would approve of a nurse sneaking medicine into food, even if there is a doctor's order. I was taught in CNA class that even dementia residents have the same resident's rights as other people, so if they, say, refused a shower, or refused a treatment, we couldn't force them to take a shower or treatment "for their own good."
They actually can do this. Usually, patients that incompetent have a guardian who agrees to abide by the rules of the nursing home and they may be drug kicking and screaming to the whirlpool room. Some of them are.
You can't let the patients run the asylum, so to speak.
Nursing homes are not like they used to be. In the old days, the nursing homes were mostly just old, worn out people. Now, they are like mental institutions as well. We have so many psych patients it's unreal.
You could look at it this way, rather than "forcing" them to comply would putting them out on the street to protect their rights make more sense than keeping them where they are safe and protected? Or would allowing them to go unmedicated and unbathed indefinitely really be helping and honoring them? You don't think the state would find that abusive?
Things are not often ideal in a nursing home. It is the nature of the beast. Most people in the nursing home are at their worst in life and when you are trying to care for adults who can't care for themselves (especially mental patients) you are in a tough situation.
Most times these nursing homes are doing the best they can, considering the circumstances.
Is this practice common?
)
:saint:
leslie :-D
11,191 Posts
no, i'm sure the state would never approve of these tactics.
the state would expect you to attempt giving meds a few different times and if to no avail, notify md...
and, write darned thorough nsg notes.
and, continue to monitor pt.
leslie