Need some advice please

[Lyla]

I had a very strange situation happen last week that may cost me my job, and I really need some advice. I work at a SNF as an LVN med nurse. I was given a report that a res. was a brittle diabetic, that FBS were erratic and high, and that the Noc. nurse had notified MD, but received no response.

I did the AM finger stick: FBS was at 405. I also had to verbally redirect res. while I administered the insulin. MD notified, but no orders at this time.

When I saw res. an hour later to give PO meds, res. was agitated as evidenced by the grabbing and twisting of my hand, the throwing of meds at me, and him stating that we were “poisoning” him and to “get out!” As a result, I let him calm down and checked back on him 15 min. later; he was asleep.

Right before lunch I was ordered to do another fingerstick. Res. was awake and I explained to him what I was doing. Res. swung at me. I blocked his hand and he then grabbed my hand and squeezed it very hard. In fact, I had a hard time getting him to let go of my hand. Again, I tried to verbally redirect and calm him.

I then asked for help, as res. started yelling “Help me! Help me!” I had an aide place an open palm on the resident’s forearm so I could do the fingerstick. It registered high, indicating that I needed to administer the insulin in the abdomen. Another aide placed his open palm on resident’s leg which prevented the res. from jerking his leg into the needle and causing harm to res. or staff. Other staff members saw me do the fingerstick and give insulin. They witnessed that no excessive force was used.

I immediately notified the MD about res. combativeness and an order was received for Haldol. I needed the chart to note Haldol order and phone number to call resident’s wife.

So, I went to DON office to find the chart. I was asked by another nurse what the res.. was yelling about. I explained that the res. was combative while getting the fingerstick and insulin and that he had to be held. She then advised me that according to the passage of a recent law, this could be considered abuse. A person from corporate was present also and overheard this nurse say the word abuse, and I was suspended while the investigation is being done.

It was not the act, but the apparent poor choice of words – when saying I needed an aide to “hold” him while I administered the insulin – that started this investigation. My aide didn’t “man handle” nor “pin” him down. We were trying to keep him safe while administering the care he needed.

I found out from a nurse practicing in acute care that they are instructed on the proper holding techniques that are not considered abusive when giving pt the care they need. This nurse told me it sounded like I used proper holding techniques with this patient.

I also talked to a nursing instructor from American River College She didn’t know about the law that holding a res in this manner can be considered abusive.

What I did is a common practice done by many staff members at this facility to protect the patient and staff, and nothing has ever been said about it being improper.

Since I have been at this facility for the past four+ years, there has been NO inservices given about this law or education about holding techniques. The only instruction I received about abuse was an outdated film showing situations of obvious abuse. I was not educated on the passing of this law during my tenure at this facility, and no instruction was given about proper holding techniques – in order to keep both res. and staff safe while still administering necessary care.

There are 4 witnesses that saw the incident that have said that no abuse was involved, but the corporate person seems determined to make an example of someone.

My question is, Do any of you know any legal issues I can use to help me? If I do get fired this seems an obvious example of wrongfull termination. I know this situation is causing a potential mass exodus of other staff because they feel it can happen to any of them now. The facility is now scrambling to get inservice dione on this subject. Thanks for any information you care to share.

[Pearlgirl]

sounds as if you are a contientious rn. you did right without even knowing the new law.

if this place makes a practice of you all being the last to find out about new legislation, and their effects on your practice, move on out.

go to a place where education and updated matierial is displayed prominently as to learn something new each time you come to work.

best wishes,

pearl

[jill48, ASN, RN]

i'm not going to fault you or say you did anything wrong because i was not there. but if it was me i would have done things a little different. first, after a blood sugar in the four hundreds (i forgot the actual number) if that doctor didn't call back after about fifteen minutes, i would have called him again. then if he still didn't call back, i would have called the medical director and got an order from him. a blood sugar that high is too dangerous to let go. i'm not saying you let it go, because you gave the insulin, but i would have made sure some physician was aware of it, at least to cover my own butt. does he get sliding scale? does the scale go that high? maybe it does and what i'm saying is a moot point. if so, disregard my ranting please. is the patient always this combative or was it due to the fluctuation in blood sugar? i wouldn't have had someone hold him still to give the injection. he was pretty much refusing it. what is the difference between holding his arm down for an injection and holding his mouth open for pills? same thing to me. i'm not trying to be rude, but that may be what all the fuss is about. especially in ltc where they say you can't put the bedrails up without an order or use a geri chair without an order because "the pt. has a right to fall", they also have a right to refuse meds. i think the proper ways of holding a patient to prevent him from hurting himself or others only applies to actual demonstrations of aggression, not when you are trying to get him to take his meds, or an injection. like i said before, i'm not trying to judge you, i'm just telling you where the investigation may be coming from. good luck. i hope it all works out and you don't get in trouble. let us know how this turns out as we could all learn from it.

[NurseCard, ADN]

It sounds like the MD was made aware that the patient had a high blood sugar, twice actually wasn't it?

Also, it sounds to me like this patient may have existing dementia, may have a guardian/POA, and probably isn't competent to refuse highly necessary meds or insulin injections. In my experience, if I've had someone that has all of their faculties refuse an insulin injection or med.... even if it's highly necessary, I'm definately not going to try to force it on the patient. I'll explain to the patient why they really need the med or injection, and then if the patient still refuses, I'll abide by their wishes and let the MD know.

In the case of a patient with dementia, who has been refusing to swallow pillls... first of all, I'll make sure that a POA or guardian has consented to all necessary treatments. Then I might crush the pills up in applesauce or ice cream and give them that way. If the patient is refusing an injection, well... to cover my butt a little further, I might let the POA know that the patient is fighting getting the injection and see what they want us to do. They I would chart that communication. If the POA wanted the injection given, well... THEN I would give the injection as the original poster did, using "safe handling techniques".

[Praise,RN]

Lyla,

Because this is a skilled Nursing Facility (LTC) the policies and procedures are much different than a hosptial environment such as acute care, ccu, or icu. The purpose of a SNF is to provide a home type environment for the residents. This is indicated by the residents bill of rights posted in your facility. Your intentions were good, however, I feel they violated the residents right to refuse the medication, depending on the patient dx., such as dementia and/or altered mental status (Even with a dx indicative of the ones mentioned, there is still a fine line). Holding the patient against his/her will (when clearly the patients is refusing) and administering the med anyway violates their facility bill of right. I would suggest you view your facility policy and procedure of what constitutes abuse. Also re-read the residents bill of rights to future guidelines in pracice, visit your board of nursing website, converse with your DON if possible.

All the best,

~Praise, RN, BSN

[Lyla]

Thanks for the advice all of you shared with me. As it turned out, almost everyone agreed it was a very gray area. My DON told the facility administrator and corporate that she would have done the same thing I did under the circumstances. The incident was going to be dropped until someone from corporate decided to make an example of this, so I decided to resign today.

I'm going to take a month off before looking for work because I need to regroup, and try to find a nursing field where you can do what is in the best interest of the patient, without the pressure of so many California laws to keep up on. Thanks again everyone.