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?
Torsades kills quickly, CHF slowly. You live in an area, like many areas in this country, that attracts bad docs. Sporificely covered areas that have one hospital in a hundred or more square mile area breeds monopolies of the bottom of class MD's. The saddest part is that these docs make more than their top of class peers because people have no choice in providers. The fact is these doctors hold the entire community's health in their hands alone and people are stuck with them, therefore the LTC is at their beck and call and the DON is under extreme pressure to appease the customer. That customer is not the LTC resident or their family, it is the doctor. I feel for the OP, because despite where she goes, she will be under this medical culture. We who live in well served areas are spoiled that we have excellent medical care available 24 hours a day. We would have not had to make that decision, because mid-levels and physicians are abundant to give us orders. Sorry you have to deal with this OP, but thankfully it sounds like you are attempting to change the status quo, praying some of your coworkers are willing to get on board for the sake of your community.
Get your NP and start making life better for these people!
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?
Wait, so are you now calling any results that are outside the lab reference range at all to the provider? Or do you have critical cut offs you call on? If all out of range results are called...not just critical...you might as well not bother calling any results at all. That would create such an alarm fatigue scenario it would be insane. The potassiums of 6.2 and the hemoglobins of 5 would get lost in an endless stream of glucoses of 134 and creatinines of 1.2, that have likely been the patient's baseline for the last 15 years. The physician would get used to Happy Hollows SNF calling and just half-asleep go ahead with their "Yeps," "Uh huhs," and "Okays."
I would not sue anyone but I would certainly take steps to keep the crazy woman off of my property.
I see it as my responsibility to inform the employer that this person behaved inappropriately. She is a loose cannon and a huge liability.
These individuals can be extremely vindictive. The job just is not worth all of the risks, internal conflict and psychological toll of witnessing unethical and inadequate patient care.
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.
This works if you live in a big city with 100 places to work. Do this in a small town where everyone is related by blood or marriage and it is career suicide.
Why are you dealing with this situation if you work nights? Did I read this wrong?
I work at a small town LTC, so I kinda get the situation you are in. We got hit for not dealing with labs.
All critical labs are called to the MD and we have a 30 minute window to get a response. They are recalled and if we don't get a response, then we call the medical director. Unless it was a stat lab, all labs should have been called to md earlier in the day.
Why are you dealing with this situation if you work nights? Did I read this wrong?
The day shift faxed the results to the doctor. I came to work and was slammed from before I even clocked it--hospice wanting me to help figure something out for a resident I'd not even met yet, a fall, dealing with short-staffed CNAs and grumpy kitchen staff. It wasn't until around 0200 that I was able to draw breath enough to realize that I'd not listened to report yet, at which point I learned about the critical lab. I put the AM dose of lasix on hold pending further instruction from the doc and faxed him the bloodwork, the information about the recently increased lasix and that the AM dose was being held until he responded. Passed it all on to the AM shift and went home to recoup for the next night.
BostonFNP, APRN
2 Articles; 5,584 Posts
Get your NP and start making life better for these people!