New nurse, need advice

[Love_Nursing17]

I'm a new nurse and been working on my floor for 5 weeks now. I just started nightshift this week and I have some concerns. I was told I have to chart my 11pm assessment by 8 pm and to start giving my 6 am meds at 4 am. I don't feel comfortable doing either of these. So my preceptor told my nursing manager that I wouldn't listen and that I was bucking the older nurses by not doing as they say. I tried explaining that I wouldn't chart early nor pass meds early unless it's in the one hour window time we are allowed, but she wouldn't listen to me. She told me I need to tone it down and take a step back and listen to what the older nurses are telling me. If I go above her and look for answers, my life will be hard at work. I feel I should keep doing what I'm doing but I'm going to get wrote up by doing so. Has anyone else had this problem? Am I wrong about all of this? I've even thought about finding a new job Bc I'm scared my license are at risk by doing such task!

[kataraang, BSN]

Your preceptor told you that you would be written up, but what did your manager say?

You are absolutely correct. Giving 6am meds at 4am is not right. Is it going to kill your patient? For most meds, likely not. However I did some searching and found from the CMS (Centers for Medicare/Medicaid Services) that supports the 1 hour window. They say:

Accordingly, scheduled medicationsidentified under the hospital's policies and procedures as time-critical must be administeredwithin thirty minutes before or after their scheduled dosing time, for a total window of 1hour.

source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R77SOMA.pdf (page 7)

Basically, if the medication is given more than once per day, you must give it within the hour. If it's a daily, non urgent medication (like a multivitamin), you can do it within 2 hours. Here is another article that addresses this as well: Guidelines for timely medication administration

I think your preceptor is a bully and is on a power trip...or she just really doesn't want to precept and is taking it out on you. You should address it with higher level individuals carefully. State facts, not feelings. Medication errors that are willfully made are grounds for losing your license. Your preceptor can't take your license away, only you can.

I really really really am sorry you are going through this...especially as a new nurse. I am new too and this scares me that there are many others experiencing just like you are. I hope things work out for the best

[Love_Nursing17]

Thank you for all of that! My manager is the one who told me I would be wrote up. I'm scared my license are going to be put at risk for doing what they are asking so I refuse to chart early and to pass meds early. I've worked too hard for my license. I just don't know if it's too soon to get a new job.

[Here.I.Stand, BSN, RN]

Um...how do you know with certainty what you will assess at 2300 at 2000? I'd love to hear what risk management has to say about that. Even if the pt is rock stable and your assessment doesn't change from 2000 to 2300, wouldn't such blatant falsification call all documentation into question?

[kataraang, BSN]

Thank you for all of that! My manager is the one who told me I would be wrote up. I'm scared my license are going to be put at risk for doing what they are asking so I refuse to chart early and to pass meds early. I've worked too hard for my license. I just don't know if it's too soon to get a new job.

Do you know how to get in contact with the DON at your hospital? Someone higher up than your unit manager. Through all of this, I advise do not let your manager/preceptor know you are speaking to administrators. You worked so hard for your license and for this job. They are putting you at risk in your career, finances, and legal too. I don't know how your hospital handles conflict within units, but maybe they might find a way to transfer you to another unit. It sounds like even if you "win" your case, they will not be happy with you. It seems like they want you charting early and giving meds early so that they can ensure they leave at 7am. That really sucks, I'm sorry

[saskrn]

You already know what's right and wrong. You could discuss your issue with the state board of nursing, and then convey that conversation to your manager. It would prove that you're correct, but your manager wouldn't be happy Regardless, you sound like you're in a bit of a lose-lose situation. Whatever you decide to do, someone is going to be unhappy.

Ultimately, patient safety is your number one priority. I would never jeopardize that or my license.

[HeySis, BSN, RN]

You do not say what type of suit you work in. in a LTC unit it use to be pretty common to start the once a day meds early, like one poster said you have a four hour window on daily's (2hours +/- the scheduled time). But now a days it's best practice to change the times on the MAR to really reflect the time it will be administered.

Example I had 42 patients in LTC, when I started everyone's morning meds were scheduled at 7am, try giving 42 LTC patients med pass from 6am to 8am. It's nearly impossible to do safely. Then they sat down and looked at the order they gave meds and moved some patients to 6am and some to 8am, then med pass could start at 5am and continue to 9am and everyone was still with in their +/- 1 hour window.

Never chart an assessment for the wrong time! IF you do an assessment at 8pm chart it for 8pm, if you don't do it until 11 pm then chart it then. doing an 8pm assessment and charting that you did it at 11pm is illegal, unethical and unsafe. Do not let yourself be bullied into this practice. If you are written up then I would go to HR and ask that you be allowed to see the write up and write your own response, such as "I agree that I was written up for not following my preceptors and managers instructions to falsify medical records by performing an assessment and charting that it was done at a later time." then I would go to the BON and report both of them.

But really, if it comes to that, you should be looking for another place of employment. Go above your manager, if its a small facility and there is no nurse above her, go to HR. Explain your concerns (use kataraang, ADN, RN link for information and take it with you.) And request further clarification of the guidlines (basically make them explain how they feel the practice you are being asked to do is legal... but doing it nicely) and a new preceptor. If that gets you nowhere then start looking for something new... in fact I'd probably be looking while trying to arrange the conversations.

[Extra Pickles]

maybe what your preceptor means is she wants you to get the bulk of your evening charting done at 8 in the evening for time-management purposes? That doesn't mean you are falsifying anything, if you document the correct time as being 8pm, you can also document everything on that assessment. Then at 11pm you could indicate something like No Changes from previous assessment if that's true, or just what the changes were, like you did a dressing change at 11pm, something like that.

I'm not quick to think this is about falsification so much as her giving you a way to get a lot of charting done earlier, when you do have the time, and then provide the updates or addendums later on? As long as you write the correct time for the original assessment and the update, what is the problem? It is a problem if you are writing that you did the assessment at 11 when you really did it at 7:45 obviously. Anything could happen, the patient could code, could get transferred to another unit within the hour, could die. But if that happens and your original assessment does have the right time of 7:45, then your updates to the chart will also have the correct times and there's nothing wrong with that.

the meds are a different thing, giving them at 4am when they are scheduled for 6am and it's an acute care floor, that's not ok.

[Love_Nursing17]

We do an assessment at 7 as well. I'm told to get the 11 pm charted at the time I do the first one but keep it in process until 11. But my thing is if something happens to that patient as you says, that assessment will be there and I can't delete it. They will then know I was charting early. To me everything has a time for purpose and maybe it'a Bc I'm new but I don't feel comfortable in any way charting early and then clicking save at 11 just Bc it saves time.

[Extra Pickles]

We do an assessment at 7 as well. I'm told to get the 11 pm charted at the time I do the first one but keep it in process until 11. But my thing is if something happens to that patient as you says, that assessment will be there and I can't delete it. They will then know I was charting early. To me everything has a time for purpose and maybe it'a Bc I'm new but I don't feel comfortable in any way charting early and then clicking save at 11 just Bc it saves time.

Want to make sure I'm understanding this right. When you say they are asking you to chart your 11pm assessment by 8, this is computer charting and you aren't actually putting anything in the chart until it is Saved at 11pm? By In Progress you mean you can change any part of it at any time, and it's not really part of that chart until it is Saved?

If I am understanding this, your assessment notes are akin to a Word document that isn't actually in the folder until it is completed and saved. IF that's so, then you aren't charting anything early, it's nothing more than a working document and when the final bell is rung at 11pm, you can complete the note and save it. If I don't understand what you're saying about your EMR, and maybe I don't, and you do have a saved note at 8pm that looks like you have documented something that hasn't happened yet, then of course you shouldn't do that.

I think I'm just not sure that what she's asking you to do is create a permanent note too early that can't be changed, and that's wrong, or if she's asking you to set up an In Progress note that can be changed as the night goes on and that's not wrong in my book.