Need advice on memo to all nursing staff that contains threat

[ms40]

to report all medication errors to state board of nursing.

A bit of background: I work in a State intermediate care facility for people with developmental disabilities. We are currently operating under a settlement agreement that is overseen by the US DOJ. As such there are numerous inspections, reviews, surveys, etc., to measure progress made toward fulfilling the requirements of the settlement agreement.

One of the most recent problems (approximately a month ago) noted by a particular surveyor was that a number of nurses had failed to sign the MAR after giving meds, treatments, etc. When this was revealed the DON and Chief Officer sent out a memo that outlined a new policy of progressive disciplinary action for making medication errors (not signing is considered an error), which to me, did not seem unreasonable. The memo left off by stating that this particular surveyor would return in a few weeks time to spend more time visiting with staff and residents which I am presuming was a bit of a "heads-up".

The surveyor made the return visit and found unsigned MAR's still an issue in some units. Some had been presigned (yikes!). There is no doubt in my mind that there are some big problems. Here's how the administration has chosed to deal with this issue. Yesterday, we received a memo from the DON and the Chief Officer regarding another new policy on disciplinary action for failing to sign the MAR or any other medication error. It is now facility policy to immediately fire a nurse that makes an error regardless of the circumstances. A strict "no-rehire" flag for negligence will be placed in the offender's personnel file and, I assume also passed on to any future employer. The facility will also report any medication error, and the offending nurse, to the State Board of Nursing for investigation.

I suppose the facility can make any policy that they like, but this seems wrong on so many levels. What recourse would I have for example, if I get fired and reported to the BON for forgetting to inital the MAR on the 1100 administration of Boost Pudding for patient "X"?

I would appreciate any feedback, words of wisdom, etc., that any of you have to offer on this situation.

[Hellllllo Nurse, BSN, RN]

I would make sure to sign everything, and I mean everything, on your MARs. I would make this your number one priority, aside from pt safety, while at work and look for a new job in the meantime.

[cannoli]

I would get out of there just as soon as I could!

[Blackcat99]

:uhoh21: Yes it's definately time to get a new job. Good luck.

[fergus51]

Charting is important. If the nurse doesn't do it or does it improperly by presigning, the employer is perfectly justified in reporting him or her. The only part of the memo that would upset me is the "no matter what the circumstances" part.

[Rustyhammer]

I guess those State Benefits were nice while they lasted eh?

-R

[bargainhound, RN]

It is always a good idea to double check your mars at end of shift....but I would leave the facility....the policy is unreasonable.

[Stitchie]

Sounds like a scare tactic and a witch hunt to me...all of us, any of us, are going to make minor errors at some point.

So what happens if you are half an hour late with your meds? Report to the BON? Seems like bringing a gun to a knifefight.

I agree, too many jobs out there ... I'd vote with my feet.

As an aside, it's this punitive, demeaning attitude of the suits and administrators that is driving good nurses right into selling real estate.

Sure, the suits can make any policy they want; it doesn't mean that good nurses should receive harsh punishment for not being 'perfect'. Sure we want quality work and the best for our patients, but focusing on the charting, MAR's, etc, seems like micromanaging and use of threats.

[kmchugh]

MAR's not signed? Nursing school 101, an action not documented is an action not done. MAR's presigned? Documentation that an action has been completed when it is not done. I believe that's fraud. I hate to say this, but I'm on administration's side here (and that happens VERY rarely).

From what you have written, inspectors came in once and found documentation errors and deficiencies. Your administration put out policy to try to correct this, which by your own admission was a reasonable policy. Administration even gave you a heads up that the surveyors were going to return. When they did return, they found nurses continuing to commit the very same errors. The "reasonable policy" was ignored by the nursing staff. Were I an administrator of this facility, I'd take pretty drastic steps, too. Sounds to me like a hostile staff that would rather see the facility closed than document properly.

Whether the medication was "boost pudding" or insulin, if it is ordered, it must be administered, and the administration must be documented. If it is not administered, that must also be documented along with the justification (i.e. patient refusal). All nurses learn that in the first semester of nursing school.

Kevin McHugh, CRNA

[FROGGYLEGS, LPN]

Here's how the administration has chosed to deal with this issue. Yesterday, we received a memo from the DON and the Chief Officer regarding another new policy on disciplinary action for failing to sign the MAR or any other medication error. It is now facility policy to immediately fire a nurse that makes an error regardless of the circumstances. A strict "no-rehire" flag for negligence will be placed in the offender's personnel file and, I assume also passed on to any future employer. The facility will also report any medication error, and the offending nurse, to the State Board of Nursing for investigation.

Pre-signing of MARs is falsifying records; that sort of thing can get you into some serious trouble with the BON. I can completely understand the facility firing someone on the grounds that they were falsifying records, especially after they have counseled the offending staff beforehand to no avail.

Blanks in the MAR is also serious, but not as much so as falsifying IMO. To say that they will report you to the BON, fire you, and give your name the stigma of being negligent over one unsigned spot seems completely over the top to me. Nobody is perfect and you can't expect that their will NEVER be a single blank on any of those MARs. To me the progressive disciplinary approach for this one seems more appropriate. They probably should fire a nurse for repeatedly not signing out MARs or for not signing out a large block of the MARs.

Did they even initiated their prior plan for progressive action before they came up with this severe one?

Our facility was also having problems with unsigned MARs. What they did was to have the supervisor check each and every MAR before we could go home at the end of the shift. That seemed to improve the situation even though it was very irritating while it lasted.

I agree with some of the others: I couldn't continue to work there if they were going to threaten to do something so dramatic over a single blank. In the meantime I'd double and triple check my own MARs before leaving. With the place threatening to turn you in to the BON for a blank, I would be almost positive that they were going to let my head roll for something eventually.

[RNPATL, DNP, RN]

I have to agree with Kevin ... MAR's need to be signed. If this facility is trying to improve the standard of care and trying to comply with regulations and the nurses are still not completing their charting, what recourse does the administration have? Having worked as an administrator for several nursing homes (the highest regulated industry in health care) I can totally understand the zero tolerance from leadership at the facility. It is a terrible thing to ask your professional nursing staff to comply with regulations and sign their MAR's, only to find out during an insepction that there are MAR omissions because nurses have not signed off the meds they gave. Yes, this would include boost pudding as well as anything else your facility includes on their MAR's.

At my hospital, we have a bar code medication administration system. Trust me, if we are late on our med pass or their is an omission, administration and quality management are made aware of it and the nurse must complete an medication error report. We do not have a zero tolerance policy ... yet, but it is the nurses responsibility to ensure that he/she documents.

One suggestion I might give is to ask your Director of Nursing to set up a quality council to review this standard with nurses and be a part of changing the zero tolerance policy. Many times, leadership resort to threats because they are running scared and feel powerless to change the problem . Nurses that come to the table and offer to help fix the problem, provide leadership with a restored sense that perhaps there is a way to fix the problem without firing people. That might be a better solution. Good luck.

PS - I would not leave, especially if you have been there a long time, but offer to help.

[renerian, BSN, RN]

I think my resignation would be one my super's desk. Just to high a stress environment. We all make mistakes. I agree the sheets need signed. What is the main problem with getting them signed? Are the workers understaffed?

renerian