medicine without a license

georgianurseRN · Nov 13, 2008

You have gotten plenty of good feedback here.Someone mentioned the "that's the way we've always done that" mentality that is often found in LTC.I'm surprised they have gotten away with this for so long-our DOH audits our charts very very closely and something like this would be caught right away.As the DON you can write a new P and P-I don't think you should make an example out of anyone in this instance.You have a big job ahead of you-you have to drag the staff into a new age and you want them working WITH you.You have to make it clear that "the way we have always done it" is NOT acceptable any longer and explain why.... Our DON came up through the ranks a few years ago-we had P and P in the books from the 70's and 80's (seriously) It's been challenging for us all but by working together we all keep up with the rapidly changing protocols.Except for the few people that grump and whine because they don't like change...We got smacked by the DOH a few years ago for circling meds on the MAR and noting "unavailable from pharmacy" It seems that many nurses did not bother to call the pharmacy,look in the emergency drug box or even stop to think about what the med was and why the resident needed it.So-several residents went days with out certain meds-one in particualr missed lasix...HELLO where is your brain? It has taken a long time for all staff on all shifts to work together and take the initiative to make that call to the pharmacy and follow through to make sure the meds were delivered or the doc was notified about any missed doses. So get busy with those p and p's....Sounds like fun

Yes, lots of good feedback for the most part. I am a little concerned that some of the nurses that replied tended to want to assume that I was only researching for disciplinary reasons, That is unfortunate and makes me wonder what kind of leadership they are being provided with. I want to note that my intent is not to make an example of anyone, not to "get" anyone, this is not a disciplinary matter for me at all. I am new DON to this facility, and through chart audits I found this issue. I will be updating p&p and doing a lot of staff education. There is very much a "thats the way we have always done it" line of thinking in LTC, my goal is to initiate and implement change, and provide the very best quality care that we can. My facility is a dedicated MR/DD facility with long term staff, it will be a big job. :bugeyes:

georgianurseRN · Nov 13, 2008

You can't compare this to the issue at hand. Oxycodone and Dilaudid are two different medications, the situation here is a partial dose of the same, PRESCRIBED medication. Apples to oranges.

The key word here is PRESCRIBED, prescribed to be given at a certain dose at a certain time. Prescribed applies to all meds given in a nursing facility of any type if I am not mistaken

SunnyAndrsn · Nov 13, 2008

Not going after anyone's license, only trying to protect them as a good DON should do. It is alright for a patient to refuse any med or treatment for any reason, it is not alright to make a decision to dose based on a residents wishes without a doctor order. That would be like allowing a patient to take only 1/2 of their BP med because they feel so good today.

I recently had a man, A&O x3 refuse to take the full dose of a medication. The dose was 4 pills, he stated he would only take two as that's what he was taking at home. I attempted to provide education on why the dosage had been increase, he stated understanding, but refused to take the full dose. This was documented, he took only two of the four pills, and the MD was updated that he refused.

The decision was the patient's--not mine--while I could have held the full dose, contacted the MD first, and then gone through this again, the reasoning was that at least he was getting some of the dosage until the MD could get involved.

I also held insulin (not sliding scale) based on a BG of 77 and the fact that the pt (differnt pt.) did not eat his meal. This was meal time coverage, and he did not eat, therefore, it would not have been good nursing judgement to give the insulin. I did fax the MD and asked for parameters to be added to his orders ("hold if pt. does not eat X% of meal).

RNsRWe, ASN, RN · Nov 15, 2008

I was floored to see this discussion has gone on this long. And with several responses that indicated that they, too, would either insist on the full dosage or give none at all!

I stand by my statements, and will further expound on them: if a nurse refuses to give any part of the medication because it's an "all or nothing" deal, then by witholding that medication she is knowingly causing that patient harm. I'd like to see her defend THAT one to the BON.

As nurses, we educate people all the time on their medications: reasons, dosages, routes, frequency, etc. And sometimes people still have different choices in mind, go figure.

If I refuse to give a patient any of her insulin because I am robot-like in my functioning (no brain, just motions) then I think I ought to be held accountable to the BON for that poor judgment. I'm witholding medications they DO want because of what they DON'T want??

That resident wanted 5 units of insulin. Those units WERE prescribed. You, the DON, have no right to insist she take the other five in order to get the first five. The doc should be notified--I still say later, hope you'd not call him every five minutes--and perhaps the doctor would change the scale for the next time. I can assure you that if I were to keep my finger on speed dial to the doc for THESE kinds of things, I'd get my butt chewed out in a heartbeat. I have no fear of doctor tantrums, btw, just know that they appreciate the same courtesies as everyone else: that if you are calling them, you have a really good reason--and pulling him out of dinner to tell him that Mrs. Smith, who is in no immediate danger, wanted five instead of ten units is ridiculous. Can the nurse not use the most basic judgement of checking that finger stick later, and if it's starting to run higher, ask the patient to reconsider?

The nurse's job is to educate the patient, offer the pros and cons of the medication options (and yes, they ARE options, including the BP meds!). If the patient would rather not, then I'd call it battery if you forced meds on them they didn't want! And essentially, THAT is what you're advocating: if you don't do it my way, taking more than you want, you're getting nada. Great nursing judgment there.

A patient who wants half her BP meds "because she's feeling so good today" GETS half her BP meds. Do I do it without questioning it? Of course not! I will talk until I'm blue, to get her to change her mind, but ultimately, I CANNOT just force two pills down her throat--NOR can I say 'oh, you feel that good, you just can go without any at all!'

This all smacks of the whole Big Brother thinking: that we the nurses must run over the lives of competent people 'for their own good'. May I never fall under that kind of care.

mscsrjhm · Nov 15, 2008

This is the wild thing about conversing on the internet-everyone sees a scenario differently in their head, and that is what they base their posts on.

With the original post-I imagined a long term and frequent problem at a ltc facility, and a professional is attempting to gather information.

Every nurse has encountered infrequent episodes of patient refusal. Its a judgment call. Every situation must be decided differently.

Notify the Physician first and foremost. But sometimes, due to time restraints, we give what we can, fax a note to the Dr., or somehow leave him a message, chart it, and it's all good.

However, dose adjustment is a Physician's job, not ours.

Pretty sure every facility medication policy states notify the Physician for refusal or any questions re dosage. If the dose is "10mg", then that is what we are legally to give. Don't think you will even find this scenario addressed in any medication P&P.

Sometimes a Physician will write the order "pt. may refuse" to prevent those frequent phone calls.

Re: insulin. Do you really think it is okay to give a reduced dose, check their blood sugar later, and possibly convince them to take the remainder- thereby splitting the dose? This is very, very, very not good.

If anyone has facts instead of opinions, I think we would all like to know the answer.

Doing a quick google search, everything I see indicates Physician notification, as only accepting 1/2 the dose is refusal.