New DON and new rules

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I work at a LTC facility in Ohio on the night shift, and I recently have had several run-ins with the DON about her new rules. I've been working there for over a year and a half, and had never been corrected before about my charting or my nursing decisions, but now this new DON is enacting some new policies I feel are not only neglegent, but also over-step her authority. I am looking for some insight before I inform her that I need to have a sit down discussion about her rules and the way I feel I am being treated.

The first incident happened the weekend before last, when a nurse who was supposed to have charge of a floor with 38 patients, called and QUIT 25 minutes into her shift. I called the DON (she was "on call") to ask what her plan was. She said I would need to take another set of keys and another floor as well as the floor I was already assigned to. She said she COULDN'T come in because she was 600 miles away in another state. Again, the next night, I had to do the SAME thing because she was still there and NO ONE was found for the other unit in 24 hours when she was already aware of the fact that the nurse was scheduled for Sat and Sun. On Mon morning she pulled me into her office, claimed that a patient heard me say, "don't come to me unless you're dead or dying" (something I would NEVER say), and that she SHOULD write me up, but that she didn't want to get off on an adversarial footing with me. I told her I would NEVER say anything like that, and I refuted the claim. She accepted that, but said that there may be times I have to take two units (I THOUGHT there was a ratio that was illegal and that I did NOT have to accept the responsibility of another unit I was not assigned to. It is also common practice that a unit manager be called in at those times. At least that was how it used to be BEFORE she became DON).

The second incident REALLY angered me on many levels, but I felt as if I were being bullied and could not do anything about it. She enacted this new rule that all nurses had to notify HER before calling the physician to have a patient sent out to the hospital. I had an elderly female patient who I already knew was positive for UTI, who had a DRAMATIC change in physical and mental status (she can usually ambulate to the toilet, but lacked the strength to take one step; she can usually speak intellgibly and with appropriate content, but I could not understand anything she tried to communicate). I called the DON, as she requested, and she said, "No. We don't send people out to the hospital for acting funny." and suggested I get lab work that would take days to get back, and even said, "I wouldn't call TONIGHT, though". So I called for the labwork and CXR anyway, and charted that I had notified her (including her name), wrote the incident report because the patient was lowered to the floor due to weakness, and reported to the dayshift nurse about her condition. The day shift nurse ALSO thought she needed to be sent out, but was also intimidated by the DON. The next day I worked, the DON stated, "Don't chart my name in the chart. You can chart 'oncall RN', or 'DON', but we don't use other people's names in our charting".

So my questions are: CAN I refuse to take on another unit if I don't feel I can safely manage them all? I know I can ignore her and call the physician and have a patient sent out anyway, but can she legally reprimand me for that? Can she really even tell me NOT to send her out? Can she make herself physically unavailable in the event that she is needed in the facility when she is oncall?

I feel like she is taking liberties with my license that I do not accept. I KNOW she doesn't want anyone sent out because she wants to keep the census up. And I definitely know she made up that stuff about a patient overhearing me say not to bother me to try to intimidate me into doing whatever she says, and that her patronizing tones and speech are a form of verbal/emotional abuse. But what are my options? Am I just going to make an already hostile situation worse?

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Specializes in LTC.

Good Lord.

We have to notify the DON here, but I usually do it with a text.... "I'm sending Ms HerpaDerp out for XXX" She likes to keep track of the census. What you may consider is notifying the family, "Mom is doing terrible! She's having quite a lot of difficulty standing and walking, and the doctor isn't here today."Most families will alarm appropriately, and bring up a trip to the ER. You can enthusiastically agree, tell your DON the family demands the patient sent out, and go ahead and call for transport. If she still fusses, call the family and tell them the DON, (Ms, FullNameHere) will not allow you to send them out.

Seriously. Put her on the spot. Hey, it's a little passive aggressive, but it's best for the patient.

I do believe you CAN refuse to randomly double your assignment, because she doesn't feel like coming in. Do you not have PRN staff at your facility?

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Specializes in Critical Care, Education.

I don't know what state you are in, but in Tx we have a legally defined "nurse patient duty" that requires the RN to do what she is supposed to do, by virtue of education and scope of licensure... no matter whether he/she has been directed to do otherwise. It supercedes the old "captain of the ship" that allowed RNs to avoid responsibility if they were "only following orders".... So, if your assessment skills and knowledge indicated that the patient needed urgent medical intervention, you would be expected to take the appropriate actions - despite what your DON said.

We also have the Safe Harbor protections... whenever a nurse feels that their assignment is beyond their capability they can file a formal notification with the employer letting them know the nature of the situation. They then have to make a detailed report at the earliest possible time available. If the nurse has gone through this process, he/she is protected from liability that may arise due to the circumstances that were described. This does not provide protection for personal actions or errors, just for things that may arise due to the lack of staff, inadequate equipment, or whatever the problems were that were cited in the safe harbor claim. These claims must be reviewed by the organization's peer review process. (In Tx, any organization that employs 10 or more RNs must have a formal Peer Review process).

On a side note, I hope the OP is also looking for another job. This doesn't sound like a place that supports high quality or patient safety.

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Leave.. get a lawyer on your way out. This so called DON has no clue as to resident care and your license is flapping in the breeze.

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Specializes in Med Surg - Renal.
But what are my options?

You only have one option: Leave.

Your facility hired an idiot and after this one leaves, they will hire a different idiot.

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Specializes in Psych ICU, addictions.

Not in LTC...but in psych, we do notify the DON or ADON before we send a patient out. They can't overrule the MD's decision, though. But they do want to be aware of it, plus an incident report needs to be filled out for it.

As far as refusing the assignment, I don't know how the Ohio BON works, but generally most BONs indicate that it's up to the nurse to determine if the assignment is unsafe before he or she accepts it.

Legally you can refuse it. However, unless you have unions, ratios or safe harbor laws that you can use as protection, you can suffer consequences from your employer for refusing...and unfortunately, that includes termination. A rational and sane employer would usually not resort to firing...however your DON's behavior sounds neither rational nor sane.

I agree with those who say to get out of there. Start looking for something else now and as soon as you land another job, give notice. Until then, do your best and CYA. And if you do end up getting fired for refusing to cover two units, better to be fired than lose your license.

Best of luck!

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I am thinking this DON was hired to clean house, so they can hire cheaper help. Look for new job, ASAP.

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Thank you for the responses. I AM currently looking into other employment (besides the fact that I feel like my license is in jeopardy every day I spend there, I also want to get out of LTC--I am open to LOTS of possibilities). I have also made up my mind to REFUSE to endanger a patient by "following orders", and put my own career and future on the line for her absurd rules. I really would prefer she fire me. I'll just get unemployment until I have my next job since I WILL have grounds for wrongful termination. So I will have plenty of free time to find a GOOD position.

I must admit that I felt TERRIBLE about following her orders! I felt extreme guilt. The patient later needed clysis because we couldn't access her fragile veins and she became dehydrated. In the hospital, she could have had a PICC placed. Actually, the night that happened, the DON asked me what her code status was and when I said, "DNR-CC", she said we should think about getting a HOSPICE CONSULT! The patient is NOT terminal. She had two acute illnesses (the UTI and later, after the CXR, we found out she had some small infiltrates). There's a male patient I take care of too, and he had a stroke and has not been able to eat or drink due to dysphagia, she ordered MARINOL, and the man is already miserable because he's hungry and CAN'T eat, and she just ordered something that would make him MORE hungry. The doc ordered an EGD and the hospital refused to do it because he couldn't swallow something for the test. They won't okay a G-tube without EGD results. So the "answer"? hospice. To me, speaking as someone who has seen him 40 hours a week for a long time and knowing his condition and family's/POA's wishes, it's inappropriate.

The aspect that really bothers me is that I have been working that unit for a year and a half. I KNOW these patients! This woman hasn't even SPOKEN to most of them, she hasn't been there long enough. AND, she wasn't there! I was there! I know this patient (the female patient with the UTI)! I have known her the entire time I have worked at this facility, and I have performed enough head-to-toe assessments on her that I almost immediately know when something is wrong. I feel like the DON is the nurse equivalent of Dr Kavorkian! Her answer to everything is hospice. As a caring nurse (one who cares not only about the patient, but their families as well), I feel like I am doing wrong by them, and I guess that is why I have stayed so long. I felt like I needed to protect them.

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My only complaint with your post is that Dr K was sought out by the persons he helped die, he did not commit euthanasia on the unknowing. Try contacting the ombudsman, the DON is not acting in her patients best interest. good luck.

Thank you for the responses. I AM currently looking into other employment (besides the fact that I feel like my license is in jeopardy every day I spend there, I also want to get out of LTC--I am open to LOTS of possibilities). I have also made up my mind to REFUSE to endanger a patient by "following orders", and put my own career and future on the line for her absurd rules. I really would prefer she fire me. I'll just get unemployment until I have my next job since I WILL have grounds for wrongful termination. So I will have plenty of free time to find a GOOD position.

I must admit that I felt TERRIBLE about following her orders! I felt extreme guilt. The patient later needed clysis because we couldn't access her fragile veins and she became dehydrated. In the hospital, she could have had a PICC placed. Actually, the night that happened, the DON asked me what her code status was and when I said, "DNR-CC", she said we should think about getting a HOSPICE CONSULT! The patient is NOT terminal. She had two acute illnesses (the UTI and later, after the CXR, we found out she had some small infiltrates). There's a male patient I take care of too, and he had a stroke and has not been able to eat or drink due to dysphagia, she ordered MARINOL, and the man is already miserable because he's hungry and CAN'T eat, and she just ordered something that would make him MORE hungry. The doc ordered an EGD and the hospital refused to do it because he couldn't swallow something for the test. They won't okay a G-tube without EGD results. So the "answer"? hospice. To me, speaking as someone who has seen him 40 hours a week for a long time and knowing his condition and family's/POA's wishes, it's inappropriate.

The aspect that really bothers me is that I have been working that unit for a year and a half. I KNOW these patients! This woman hasn't even SPOKEN to most of them, she hasn't been there long enough. AND, she wasn't there! I was there! I know this patient (the female patient with the UTI)! I have known her the entire time I have worked at this facility, and I have performed enough head-to-toe assessments on her that I almost immediately know when something is wrong. I feel like the DON is the nurse equivalent of Dr Kavorkian! Her answer to everything is hospice. As a caring nurse (one who cares not only about the patient, but their families as well), I feel like I am doing wrong by them, and I guess that is why I have stayed so long. I felt like I needed to protect them.

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Specializes in kids.
Thank you for the responses. I AM currently looking into other employment (besides the fact that I feel like my license is in jeopardy every day I spend there, I also want to get out of LTC--I am open to LOTS of possibilities). I have also made up my mind to REFUSE to endanger a patient by "following orders", and put my own career and future on the line for her absurd rules. I really would prefer she fire me. I'll just get unemployment until I have my next job since I WILL have grounds for wrongful termination. So I will have plenty of free time to find a GOOD position.

I must admit that I felt TERRIBLE about following her orders! I felt extreme guilt. The patient later needed clysis because we couldn't access her fragile veins and she became dehydrated. In the hospital, she could have had a PICC placed. Actually, the night that happened, the DON asked me what her code status was and when I said, "DNR-CC", she said we should think about getting a HOSPICE CONSULT! The patient is NOT terminal. She had two acute illnesses (the UTI and later, after the CXR, we found out she had some small infiltrates). There's a male patient I take care of too, and he had a stroke and has not been able to eat or drink due to dysphagia, she ordered MARINOL, and the man is already miserable because he's hungry and CAN'T eat, and she just ordered something that would make him MORE hungry. The doc ordered an EGD and the hospital refused to do it because he couldn't swallow something for the test. They won't okay a G-tube without EGD results. So the "answer"? hospice. To me, speaking as someone who has seen him 40 hours a week for a long time and knowing his condition and family's/POA's wishes, it's inappropriate.

The aspect that really bothers me is that I have been working that unit for a year and a half. I KNOW these patients! This woman hasn't even SPOKEN to most of them, she hasn't been there long enough. AND, she wasn't there! I was there! I know this patient (the female patient with the UTI)! I have known her the entire time I have worked at this facility, and I have performed enough head-to-toe assessments on her that I almost immediately know when something is wrong. I feel like the DON is the nurse equivalent of Dr Kavorkian! Her answer to everything is hospice. As a caring nurse (one who cares not only about the patient, but their families as well), I feel like I am doing wrong by them, and I guess that is why I have stayed so long. I felt like I needed to protect them.[/quote

Wait a minute?:no: How can she order Marinol? she is an RN correct? What does the medical director say?

If your concerns are as bad as they sound, I would call the Ombudsman if there is no one to go to over her head....good luck!!!

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Oy. As a DON in Ohio.....a few things come to mind.....firstly yes you have a voice and CAN professionally express your concerns about an assignment that superman could not physically do: You are doing nothing wrong when you professionally voice your concerns to your supervisor: There is no policy or law against that. You have to protect your license and the residents: If your concerns are not addressed then you should contact the administrator and so on: Noone would want to work like that and it is not fair to the residents either. Everyone has a supervisor: and if your concerns are not being addressed properly or you fear retaliation then by all means go to someone else....mainly the admin is the next step up. As the DON it is our job to ensure that there is adequate staffing to ensure the care is being done: Why in the world your DON would be on call and 600 miles away makes little sense: Don't go out of town if you are on call: So that mistake is on her.....but even being out of state.....did she assist in contacting other staff to assist? Is there an ADON? She should not have just left it like that without attempting to assist in calling to find coverage. Talk to your administrator professionally about your concerns.......approach it not as if you are condemning the DON ....but go prepared to discuss concerns at a resident care level. Also don't just bring the problems...you should also have in mind a few solutions that you think may work to solve the problems too.....be as positive as you can and help be a part of the solution....maybe after you could suggest a meeting with the DON with the admin present to further discuss the issues.

Ultimately as a licensed nurse your obligation is to notify a resident's physician of a change in condition: it is acceptable to also notify the DON of the issue and the MD response- if this is her preference but first and foremost the MD should be contacted first and treatment initiated. No of course we don't wish to send every UTI to the ER-esp if we can successfully treat these in the facility: that is why your assessment skills and communication to the physician is key: As a DON we can try and assist nurses in suggesting treatment that are the standards of care-or with our experiences in nursing things that have been successful in the past to suggest to the physician-but ultimately it is the physician who orders the care not the nurse-DON or not-. I would advise you to contact the physician first with changes of condition then your DON can be made aware of what occurred and what the physician ordered treatment plan is....but please always notify the doctor no matter who tells you differently. Cover yourself and ensure the resident is getting the care that they need.

You sound like a great, caring nurse....one that LTC needs. Don't give up on a job that you like and working with residents you obviously care about without seeing if there are ways in which you can improve things for yourself and for the whole facility. (:

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Based on what you stated in your original post, I would just look for another job. It sounds to me that you have major differences with the DON and her ideas. She is going to win the contest or you will tire of butting heads with her. Just go somewhere else and save yourself a lot of grief.

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