My DON came to my house today

[mtjoanna]

I'm an RN who works at a small-town nursing home, owned by a large, multi-state company; I work nights--1745 to 0615 (or until the day is done--you know how it is). So here's the situation: geriatric pt with increasing edema. We attempt to contact the doctor but get his PA instead. The PA orders an increase in Lasix to 40mg po qDay x 3 days and a BMP with f/u with the doctor. The blood work gets drawn and sent to the lab the next morning and the first dose of Lasix 40mg is given. The BMP reveals a critical low potassium (2.9); results are faxed to the Dr. with a request for further instructions, which don't come that day. During the noc shift, I put the next dose of lasix on hold pending further instructions from the doctor and I fax him again and pass this on to the on-coming shift via verbal report. My DON comes in later, can't figure out why I would have held the lasix when it was a brand-new order, goes into a tizzy fit and COMES TO MY HOUSE!!! She pounds on my door, waking me up from a sound sleep, to demand to understand why I thought I could put a one-dose hold on that Lasix. She tells me that it was an inappropriate action on my part and orders the day shift LPN to give the Lasix anyway, apologizing to the doctor for my actions.

Here's my question: was I really out of line in holding one dose of lasix while waiting for further instructions on a critical low potassium? Did I overstep my legal authority as an RN? I did not d/c the order, only put it on hold pending further instructions. Is what I did so far from logical thought that it warranted her coming to my home and waking me up?

[CapeCodMermaid, RN]

Just when you think you've heard it all you come to Allnurses and hear more.

She went to your house?!?!?!.Holy crow....what a lunatic.

It seems the problems are the doctors who don't call back. If I were you and this happens again, call the MEDICAL DIRECTOR. They have to answer. It's part of their job.

[Karou]

Our doctors have made it clear that they are not to be called unless it is an after-hours emergency--and critical labs don't count to them. It drives me nuts sometimes... We have to call them ahead of time for permission to send residents to the ER, even for serious bleeding and heart attack/stroke s/sx. We also have to get specific orders for use of an ambulance, even if it is after hours and we don't have anyone who can drive the facility van. I got my butt chewed by my DON for calling the doc "needlessly" when a (new) resident had a firm, distended abdomen with pain radiating from stomach to under her rib cage with no bowel sounds. Per my DON, I'd let the resident "manipulate" me into sending her to the ER. Good idea on the time sheet; I think I'll do that when I get to work tonight.

Your DON is an idiot. Does she like sentinel events? Would she rather coddle a doctor than care for a resident? Good grief. I would not want my family member at a facility where nurses and staff are afraid to call the doctor for fear of getting chewed out, and their supervisors are only supporting this culture.

You don't have x-ray vision. While some patients can be manipulative (like those who complain of CP specifically on the day of discharge, every single time...) I don't see how atone can fake absent bowel sounds!!! You had totally objective findings that warranted a KUB at the absolute very least, possibly a trip to the ED with an impaction. Does she know bowels can rupture and perforate???

We had to call for permission from the supervisor and physician to send to the ED when I worked in LTC also. Don't think I ever had anyone say no. If I had, depending on what was going on, I might have called 911 anyway. To hell with what they say, if I believe it's an emergency then it's my responsibility to get the care they need.

[BostonFNP, APRN]

It is within your scope not to administer a medication you feel will harm the patient. If you documented your rationale and you attempted to contact the provider, the DON is the one in the legal wrong not you.

If it were my order for furosemide x3 and a crit low K came back and you held that dose for me I would be grateful.

[EmRN14]

I feel like the DON coming to your house was highly inappropriate. I would talk to your CEO or someone that would take care of that situation.

I would have held the Lasix as well. You did not overstep your boundaries as a nurse. That is your job. Like most people say "chart or it didn't happen". I would chart what happened and why you didn't give it. Cover your butt.

Also working in LTC is difficult. I worked there for a bit and I was miserable. I felt like it put my nursing license at risk. I got a job at a hospital and the patient load is much lighter and I have more support. I also feel like I am not walking on eggshells and I am not questioning my every action.

Hopefully you figure this out soon! If I were you, I would start looking into a different position where you get more respect.

[OCNRN63, RN]

As far as holding the lasix, I guess you could have just given it and put your patient into an arrhythmia. *sarcasm*

Actually, that's not such a bad idea. Then they'd have to go to the hospital where there is no dumbass DON trying to kill them.

We think alike. I would have been tempted to call the cops, and no stupid rule is worth losing my license. If the docs don't like being called, tough rocks.

[dec2007]

This whole situation is ludicrous!!! I work in an ICU, and a potassium level of 2.9 is critical, even life-threatening in a debilitated elderly person. Even if the patient is a DNR, that doesn't mean we don't treat the patient. That Lasix dose very likely would have killed that patient. I would have woken the doctor up for that value no matter how angry he would become. If I heard the slightest attitude in his voice, I would say "Jus to verify, Sir, I am writing your physican's order to administer Lasix to your **year old patient with a potassium level of 2.9, and not to administer supplemental potassium to the patient. Is that correct, Doctor?" As far as your DON.....her behavior was so far out of line and incompetent I am surprised she still has a job. She shouldn't! LTC does not exist as a haven for lazy doctors who don't want phone calls. It exists to provide the best possible care for people who can no longer care for themselves. I don't know this physician or the DON, but I believe your license is in danger as long as you work with either of them. Document all interactions with them in detail and all related patient care you give, and keep a copy for yourself in a safe place. I believe if something goes terribly wrong at your facility, your DON (with the blessing of the physician in question) will place the blame on you. Be prepared! Good luck to you!!

[ambr46]

What's with these crazies? D.O.N coming to your house??? That's absolute nonsense. Hasn't she ever heard of a phone?

[Beth0504]

Life is too short to work for someone like that. Are there any other job opportunities that you can pursue?

[Here.I.Stand, BSN, RN]

You learn about the connection between K+ and Lasix during first semester of nursing school. Giving it to someone w/ a K+ of 2.9 is negligent nursing; holding it is prudent nursing--not practicing medicine.

And coming to your private home to discuss work...good night!! She is so far past the line she can't even see the line anymore!! I would seriously consider reporting her for that. And I would definitely start looking for a new job. That place sounds horrible all around, from the culture that favors physician comfort over resident safety, to the bat guano crazy DON.

[RescueNinjaKy]

I would've held it and told the don I don't think it's safe to administer, if she wants to it given then she can give it herself. Document document document.

[lindseylpn]

Since its a large corporation I would call corporate or something and make a formal complaint about her coming to your house. That is totally unacceptable.

[canigraduate]

You could also report the facility and the individual docs to the state and to CMS for neglect.