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?

[RescueNinjaKy]

I've seen torsades with a 2.9 potassium level. She went to vfib and everything and had to be shocked. Good thing she made it.

[melaniefrench]

Completely inappropriate for her to come to your home.

[flying_ace2]

I'd tell that DON if you catch her on your property again you'll press charges for trespassing and get a restraining order.

Going to your home and harassing you is NOT OK.

Anybody who comes pounding and yelling at my door will be escorted off the premises by someone in uniform.

You also need to write her up and report her for her conduct. What she did is so far beyond acceptable that she needs to be slapped back into reality before she does something even more criminal.

This, a million times over. There is absolutely no reason for somebody to come harass you at your house, and this DON would learn that the hard way from me.

[mtjoanna]

I did just have a meeting with the administrator of the facility. Talked about my level of discomfort with having work invade my home and the fact that a reasonable nursing action on my part caused such hullabaloo. I've always been very aware of the "authority" of authority figures (growing up as an army brat helped cement that respect), so one of my struggles since graduating nursing school has been learning to rock the boat when necessary. I have developed a thicker skin and have called and insisted on care for patients, but it does continue to be a struggle for me. The times that I have been most insistent have been validated by the findings when finally evaluated, but it is definitely an area that still requires some work. I'll get there. In the meantime, I have 2 glorious days off that I fully intend to enjoy. This fall weather is perfect for riding! Thank you all for your support and words of wisdom.

[blondy2061h, MSN, RN]

I really thought when I read this title it was going to be about what a nice, working relationship you have and how she came over to have tea with you.

My mind is blown.

[RNKPCE]

I did just have a meeting with the administrator of the facility. Talked about my level of discomfort with having work invade my home and the fact that a reasonable nursing action on my part caused such hullabaloo. I've always been very aware of the "authority" of authority figures (growing up as an army brat helped cement that respect), so one of my struggles since graduating nursing school has been learning to rock the boat when necessary. I have developed a thicker skin and have called and insisted on care for patients, but it does continue to be a struggle for me. The times that I have been most insistent have been validated by the findings when finally evaluated, but it is definitely an area that still requires some work. I'll get there. In the meantime, I have 2 glorious days off that I fully intend to enjoy. This fall weather is perfect for riding! Thank you all for your support and words of wisdom.

And the administrator's response to the DON coming to our house? Does the admininistrator have enough clinical background to appreciate why you held the lasix and the communication issues with doctors after hours?

[Here.I.Stand, BSN, RN]

Good for you!! I was a USAF brat myself...I still can't call my kids' teachers by first name. But sometimes boats need to be rocked.

Enjoy your days off with your horse in the glorious autumn!

[dec2007]

I did just have a meeting with the administrator of the facility. Talked about my level of discomfort with having work invade my home and the fact that a reasonable nursing action on my part caused such hullabaloo. I've always been very aware of the "authority" of authority figures (growing up as an army brat helped cement that respect), so one of my struggles since graduating nursing school has been learning to rock the boat when necessary. I have developed a thicker skin and have called and insisted on care for patients, but it does continue to be a struggle for me. The times that I have been most insistent have been validated by the findings when finally evaluated, but it is definitely an area that still requires some work. I'll get there. In the meantime, I have 2 glorious days off that I fully intend to enjoy. This fall weather is perfect for riding! Thank you all for your support and words of wisdom.

mtjoanna, I would say for the length of your experience, you handled yourself in an exemplary fashion, and you are doing great at appropriate assertiveness and developing a thicker skin. ( I'm still working on

those things after all these years.) Enjoy your time off, and be happy that you have good assessment skills and nursing judgement!

[CapeCodMermaid, RN]

One facility I worked at as a supervisor got tagged because the MD wasn't notified of an abnormal lab. There was absolutely no harm to the resident but such is life in a SNF. We had to write a plan of correction ensuring the MDs would be notified every time the lab was abnormal and part of my job was to do an audit to make sure this was done. One of the MDs pitched a fit when one of the nurses called him with an abnormal BUN. I don't remember the details but the BUN was one point higher than the high normal (but really good for this particular resident). He started yelling at the nurse about using her judgement .... She handed me the phone and I explained to him it was part of our plan of correction...abnormal is abnormal. He said he didn't want to be called. I told him he would have to come in and write specific orders for EVERY one of his residents with parameters for notification. He said "That would take a week!!" He decided it was less work for him to get a phone call.

Don't be a doctor with patients at a SNF if you don't want calls at any time...be a dermatologist.

The point is-we always should do what is best for the patient using our critical thinking skills. I would have held the lasix. I would have called the medical director if the MD didn't return the call. Faxing a critical lab is not prudent practice. Document what you did or didn't do and why.

The DON needs to go away.

And finally, many of these posts mention legal action....who would sue whom?

[BostonFNP, APRN]

Everyone sue everyone! That's the society we (unfortunately) live and practice medicine/nursing in.

Calling for every abnormal lab isn't good medicine, its unfortunate that the facility had to default to that, and even more unfortuante that the one abnormal lab that nursing missed resulted in that kind of slap on the wrist that ends up hurting the patient, the nurses, and the providers. I am sure for that one missed abnormal lab the provider had skipped over dozens accidentally. Having nurses that can use their fund of knowledge and experience to call and remind me of something I may have missed is vital to my practice.

[icuRNmaggie, BSN, RN]

If an angry manager from my place of employment was banging on my door, I would call the police to have her removed.

That police report would be proof of harassment and a hostile work environment and attached to a cease and desist letter from my attorney.

I would file a restraining order to keep her off my property.

[Sugarcoma, RN]

I did not read every comment, just the first few from OP. Yes I would have held lasix for a patient with a K+ of 2.9 when it was not addressed. Lasix will cause an even further drop in K+ and at 2.9 that patient really couldn't afford too much more of a loss. The lasix was ordered for increased edema. I am assuming the patient did not have trouble breathing as they are not in a hospital. Where is the harm in holding one dose until the critically low K+ is addressed?

I too would have sent out a patient with no bowel sounds, ab pain, and a firm distended stomach.

I work with docs like this. They only want to be docs from 9-5 and they get all out of joint when we do things without consulting them, yet they are unavailable to us. The thing with these types of docs is that you are da$n#! if you do and da&ne* if you don't. Could you imagine how fast they would throw you under the bus if you did not call a bus for a patient who ended up perfing? Or if you had sent the lasix patient into a lethal arrhythmia due to hypokalemia. You can't have it both ways. I would call with everything, which is what I do at work. They don't like it, they yell and gripe and groan, but my patient's get what they need or at least I know I did what I could to make sure my concerns were addressed.

Your don sounds like an idiot and I would never tolerate my employer coming to my home unless it involved a serious emergency. Is there anyone higher up you can complain too? That type of behavior is way out of line. Seriously she sounds a little unhinged.

I would let this DON know that I am governed by the nurse practice act of my state, not her opinion, and that I will act in accordance with that act and not her opinion. I do not know where you live but I do know that my act includes the prudent use of nursing judgement. Firm distended abdomen with no bowel sounds = further assessment needed period. Could you imagine sitting in a court of law and trying to defend not sending this patient out for further assessment if this patient ended up with a perfed belly? Umm sorry but our docs don't like to be called at night and the DON comes to my home and rants like a crazy person if she doesn't agree with my actions? She is nuts if she doesn't understand why you did what you did in both instances.

You need to find a new job ASAP. At the very least I would go above this DON just to make sure your concerns are documented. It may not change anything and probably won't but at least you will have tried and then can go about seeking new employment knowing you did all you could.