LPN Supervisor Would Not Let Me Call Doctor

[Googlenurse]

At the LTC in Ohio I work at, we had a patient that was very lethargic. His vitals were stable but his bp was 88/50. This was around 0200. Patient was trach, vent, GJT, and had a PICC line. The supervisor (who is an LPN) stated to not bother the doctor and to just pass it on next shift. The patient did eventually get sent to an acute hospital two days later.

I am an RN  with 15+ experience and she is an LPN with 8 years experience. But she has been working at this facility for 7 years, and I just got here 1 month ago.

My question is this: If something happened to the patient, would  I be on the hook because I have the higher license, or would we both had taken the fall?

Also, I thought an LPN could not supervise an RN clinically?

Like, an LPN cannot tell an RN what to do clinically even if supervising?

[Tenebrae, BSN, RN]

'I will need you to document this in the patients notes". people like that are very good at saying something, I don't trust that they won't turn around and go 'I never said that' if it goes belly up

And then do what needs to be done. Document the hell out of it in the patients notes including condition, deterioration and why you contacted the doctor. 

No ones going to tell me how I look after my patients 

[No Stars In My Eyes]

In a few states there are laws and/or facility 'rules' that only allow an LPN to be charge or supervisor if there is an RN in the building. That doesn't say the RN is responsible, exactly, but it does seem like splitting hairs, because what does 'being in the building' do but justify using an LPN where previously only an RN was allowed?

[CommunityRNBSN, BSN, RN]

I’m not crazy about the use of “let” in the title. I know what you mean— your supervisor told you not to. But I am not a child who needs permission to act in good faith to care for a patient. 
 

At my outpatient clinic, there’s a rule that we can only respond to emergencies that happen IN the building. Not out in the street. A few years ago, a person overdosed outside— maybe ten feet from the door. Someone immediately called 911 of course. The other nurse and I went to grab the Narcan out of the cabinet. The MD who was working told us not to!  “He’s not in the building. We can’t help him.”  Um, okay, but he’s visibly turning blue. Like… yes, the MD was our supervisor, and yes, he was telling us to follow clinic guidelines. But sometimes you just have to follow your own judgement! (We ignored the doctor.) 

[summertx]

Sounds like the patient shouldn't be at an LTC, with only few staff that won't work out very well.  

Ultimately the doctor is responsible for admitting this patient and allowing them to be at an LTC (along with director of nursing/admin). Time to call that Dr and at 0200am, they best expect a phone call. 

[CharleeFoxtrot, BSN, RN]

On 10/7/2022 at 10:19 AM, summertx said:

Sounds like the patient shouldn't be at an LTC, with only few staff that won't work out very well.  

Welcome to the real world, patients in the SNF/LTC are sicker than ever before due to how our health care system works. 

[kbrn2002, ADN, RN]

On 10/5/2022 at 1:08 AM, Googlenurse said:

So I’m only responsible for the clients in my care? I’ve read the Ohio Practice Act. 
I kind of figured I was only responsible for clients in my care. 
I did read some old threads from 2009  on Allnurses on this subject and some posters were saying the RN is responsible for the whole building even if those patients were not assigned to him or her. 

While you are only responsible for the residents under your direct care you also as the only RN in the building would be expected to respond to any situation requiring an RN assessment as the LPN can't perform the assessment. I worked with some amazing LPN's in LTC but I have to admit when there were nights with multiple falls or changes in condition in the building I really disliked being the one person who had to leave my wing and respond. It quite often put me pretty far behind on my own work.

[Googlenurse, ASN, BSN, RN]

8 hours ago, kbrn2002 said:

While you are only responsible for the residents under your direct care you also as the only RN in the building would be expected to respond to any situation requiring an RN assessment as the LPN can't perform the assessment. I worked with some amazing LPN's in LTC but I have to admit when there were nights with multiple falls or changes in condition in the building I really disliked being the one person who had to leave my wing and respond. It quite often put me pretty far behind on my own work.

That’s what I am afraid of. I don’t want to be behind in my work because I’m too busy doing someone else’s job. 
If the Lpn  on the floor has 30 patients, and I have my 30, why am I expected to do an admission, esp with the Lpn supervisor is in her office talking loudly on her cell phone?

On top of that, the other day we had an agency RN on the floor  that refused to do an admit. She claimed agency nurses don’t have to do admits(not sure where she got that information). I refused of course. The superior argued with her for like an hour.  

[offlabel]

On 10/4/2022 at 11:17 AM, Googlenurse said:

 

At the LTC in Ohio I work at, we had a patient that was very lethargic. His vitals were stable but his bp was 88/50. This was around 0200. Patient was trach, vent, GJT, and had a PICC line. The supervisor (who is an LPN) stated to not bother the doctor and to just pass it on next shift. The patient did eventually get sent to an acute hospital two days later.

 

Lethargic at 0200? Need more information.  His mean arterial pressure is between 60 and 65 and he's sleepy. You don't say what the sleeping BP normally is, but if I had to guess, it wouldn't be to far remote from what you measured.  I would have told you the same thing. Wait until day light hours and then call. No physician would have come in for that, nor transported the patient to a hospital. If the patient were awake and the mean pressure was less than 60, that would be another story. 

[offlabel]

On 10/5/2022 at 10:31 AM, Susie2310 said:

As nurses we are the patient's Advocate.  In my state, nurses have autonomy in their right and obligation to report to the physician patient assessment findings/other info that indicates an adverse change in condition or that is otherwise concerning, and to use the chain of command when necessary to obtain necessary medical care for the patient, and no supervisor or administrator is permitted to interfere with this.

For myself, the risk of losing my license would be an important concern, but even more than that, I would be concerned about potentially being sued for negligence if an adverse event occurred and patient harm/injury resulted.

No one is questioning the role of advocate for the nurse. But we can't cloak ourselves in such a noble title if we all we do is reflexively respond to wooden parameters completely removed from the context of the actual patient situation. You don't need nurses for that. A freshly trained EMT could be given a quick reference card with hard and fast numbers to call the doctor for. We need to move away from the "my license is on the line" mentality, firstly because it is incompatible with advocating for the patient in that it puts the nurse's interests above everything else and secondly because it can be (and has been) used as an excuse to hide behind passing the buck to someone else and ceding our autonomy and scope to someone else. Given the scenario, there was no reason to make a 0200 phone call to the physician at that time, and that would be a completely defensible nursing call. 

[summertx]

37 minutes ago, offlabel said:

Lethargic at 0200? Need more information.  His mean arterial pressure is between 60 and 65 and he's sleepy. You don't say what the sleeping BP normally is, but if I had to guess, it wouldn't be to far remote from what you measured.  I would have told you the same thing. Wait until day light hours and then call. No physician would have come in for that, nor transported the patient to a hospital. If the patient were awake and the mean pressure was less than 60, that would be another story. 

Nurses aren't superhuman. She stated the pt was very lethargic. Something is wrong. I'm not sure if the OP walked in to this situation or if this bp was common with this patient. Sometimes the 0200am phone call is necessary based on the nurses circumstances and patient load. SNF are a 24-hour facility and physicians or an on-call line 'should' be available for support at that time, I'm not saying they support us, but if a patient needs a higher level of care or assessment it should be available. We need more information with the patient; heart rate, SpO2, and respiratory rate. I'm not comfortable with a MAP of 60 in a trach/vented patient at 2am. Some paraplegic / c-spine patients who are immobile cruise with a bp of 88/55 and they're asymptomatic. The pt was on a vent and had a trach with a PICC line. Something to me spells sepsis. So if this is progressing and wasn't caught at 8am, the nurse is not always in a cookie cutter situation.

[offlabel]

1 hour ago, summertx said:

I'm not comfortable with a MAP of 60 in a trach/vented patient at 2am.

So, that's my question...why not (the MAP was 63)? The MD would be very aware of the risk of sepsis in this population. What would you have him or her do based on that blood pressure alone?  What does *very* lethargic even mean at 2 AM in a trached, ventilated, completely stable patient with a g-tube? Going to guess that patient's baseline LOC allows for expecting somnolence/lethargy especially at that time of night. I wasn't there and this conversation has less to do with call/don't call scenarios than nurses making an informed, rational defensible nursing decision as opposed to a knee jerk response to what very well may not be a problem at all. If you'd call for that, have at it. I wouldn't.

[summertx]

6 hours ago, offlabel said:

So, that's my question...why not (the MAP was 63)? The MD would be very aware of the risk of sepsis in this population. What would you have him or her do based on that blood pressure alone?  What does *very* lethargic even mean at 2 AM in a trached, ventilated, completely stable patient with a g-tube? Going to guess that patient's baseline LOC allows for expecting somnolence/lethargy especially at that time of night. I wasn't there and this conversation has less to do with call/don't call scenarios than nurses making an informed, rational defensible nursing decision as opposed to a knee jerk response to what very well may not be a problem at all. If you'd call for that, have at it. I wouldn't.

This was at 2am when the nurse doesn't have resources at their disposal. The nurse is most often working alone at an SNF, they're lucky there if there is an additional competent nurse. The pt had a trach (suctioning?), vented (Sp02? I'd bet it wasn't 98%), pt with gtube (feedings?, have to always correct staff and do it yourself to keep their head elevated, or else they will tank to aspiration pna) and a PICC (on IV antibiotics with no pump). The risk is too high. I've seen these patients code at shift change, or having to be sent out via 911 and get a call that they expired at the ER (not my patients). I'd rather not do CPR and not wait until the patients heart rate is 35 to figure out they have to be sent to the ER. And CPR on a trached patient?