New Nurse New Problems

[ca.as.lvn]

So I finally started my first nursing job as a LVN. I currently work in a Memory Care facility. Before starting my new career as a LVN, I worked in Memory Care as a CNA. My problem/fear is that I am not working at a reputable facility and that my license may come into jeopardy. The facility I work at is very micro-managed by the administrator/owner of the facility. His right-hand person the "Director of Operations" is also scheduled on the floor as a CNA. She this CNA has been with the facility for 8 years she was recently promoted. However, while she is at work she wears both hats. My concern is that between the two of them, they do not have much medical knowledge. Neither listen to the nurses or care too much about their opinion and hinder us from doing what we actually need to do as nurses. For example: I had a fall with my Huntington's resident 2 days ago. Her bed alarm did not go off and she was found unresponsive on the floor. I immediately called 911 and had a CNA get the paperwork that was needed for the resident to go out with and started to do my assessment on her and get her responsive. However, the admin was constantly in my way and would not leave the resident's side. When the paramedics showed up and were asking me questions about the resident such as how old, is she on blood thinners, ect the administrator stepped out of the room and sent the CNA(Director of Operations) in the room to inform me to leave and go check rooms. The rationale behind that was the longer I stayed the more questions that the paramedics would ask and they had the paperwork that they needed. I refused because she was my resident and I told the CNA that the paramedics were asking pertinent questions in order to properly assess the resident and be able to treat her. The administrator told the paramedics that they could not leave right away that we had to wait for the husband to arrive and he was about 8 minutes away. The resident came back the next day with a brain bleed and I was not aloud in the room by management when she came back only the CNA and the administrator. I did assess her later in the shift and the follow day while I was on shift. Yesterday she had s/s of a concussion and the CNA stopped me from calling the doctor or the husband because in her words" She is fine" I have only been at the facility for a week and I am unsure how much longer I feel that I will be there. I find it hard being an LVN and having to inform my CNA of everything I am doing and being questioned on what I am doing by a CNA. the other CNAs call this person in for body checks or emergencies with the residents and do not inform me of anything. There have been several other things that have happened since I have been there in my short period of time. My question to all of you is How do I handle this situation? As a new nurse and a new employee of this facility I feel as if I am stuck between a rock and a hard place

[caliotter3]

Leave and go check rooms instead of reporting on my patient to the paramedics? Past time to seek another job.

[Lev, MSN, RN, NP]

Next! Time for a new job. This place is not safe. The CNAs should not be bypassing your authority and you should not have to explain all your moves to a CNA. You delegate to them, they don't delegate up to you.

[MedChica]

This sounds pretty unbelievable;then again, I've seen too much and I'm totally cynical because of it. So, whatever. I believe it.

Do you have any other jobs lined up? LOL Make sure that documentation is up to snuff, in the meantime. If the pooh hits the fan and some family member pursues legal action or files a complaint? No one is going to protect you. You're getting named in that lawsuit alongside everyone providing care for that resident and your BON's gonna fly through that facility trying to snatch up wigs AND licenses. LOL

I'm not trying to frighten you but I've seen it as I'm sure that others have. I haven't even been a nurse a full 3 years and I've seen this sort of thing play out (bc I tend to pull PRNs at multiple facilities). So, I'm just trying to help. Documentation saves licenses. LOL That facility seems like it's trying to hide things. You've got unqualified persons holding position. Management acts as a barrier to pt care. It's a bad deal.

Then, I see this:

Yesterday she had s/s of a concussion and the CNA stopped me from calling the doctor or the husband because in her words" She is fine"

...and you didn't call? Did you document anything?

Here's the thing: You're a nurse with a CNA supervisor. LOL Your CNAs are reporting issues concerning your residents to said "supervisor" and it's a problem because you've got a bunch of random unqualified ppl making screwball decisions with real life consequences under your license. If something happens to that little woman and the pooh hits the fan, what would you say in your defense? "Uh, well, I noticed but the CNA told me not to call and so - I just didn't because - well, she's the Director of something and because...I was told - I just thought...that...."?

No, ma'am. You monitor and if something's happening to one of your people, particularly, after a trip to the hospital? You call that provider if it can't be rectified on your end, tell them what's going on/request whatever you need and secure orders.

Maybe the doc would've told you to send the pt right back out.

The administrator told the paramedics to wait '8 minutes' for the husband before sending an unresponsive resident with a fall/head injury to the hospital? That's just stupid. "8 minutes" could morph into 30. Surprised that the paramedics didn't fight you guys on that. The patient is what matters, here. Getting the pt to the ER is priority. The administrator should've explained the severity of the situation to the family member. If he was that freaked out over 'too many questions asked', you'd think that he'd want to get the pt the heck out of the building. Your CNA DOE, MD (lol) could've just given the family member directions to the hospital over the phone, in the meantime.

Why in the world would your administrator tell your CNA supervisor to inform you to leave while you're giving report? How did he conclude that the paramedics had enough info?

Your pt comes back and you weren't allowed in the room? Strange.

Unless the individual's getting ready to complete undergrad, I don't understand a CNA being given the title, Director of ... Operations? Why not hire a REAL DON? She can't exactly supervise you in a CNA capacity. She's carrying out tasks based on poor nonclinical judgement and doesn't have the wherewithal to recognize it. Clueless. That's why she was ferrying messages between the two of you. No one has time for that kind of crap in an emergent situation.

[ca.as.lvn]

Of course I informed the family. The husband came to the facility about 30 minutes later and I spoke with him. I continued to monitor her and check vitals every hour for the remaining of my shift all WNL. The fact that the CNA stopped me upset me because it was not her place to do so. I am finding it hard to answer to someone who does not have the medical knowledge to make informed decisions. I am the only one in the facility that's license is on the line. I really do not know how to go about handling these types of situations when the Administrator is the owner and my direct supervisor is a CNA. I find it odd and off . I am trying to find another job but being without 6 months experience as a working LVN is making it hard to do so. I have caught multiple errors within the short time I have been there and I am trying to assert myself more as a nurse.

[Nibbles1]

You could report it to DADS while you run from this job. Please go find another job. This is too weird. I refuse to take orders from a layperson. CNA as a DON? No thank you.

[jadelpn, LPN, EMT-B]

Call your state BON, call your malpractice insurance. If you do not have malpractice insurance, you need to get it.

Who is the medical person (MD/NP as well as RN) who is "on call" or whatever it is stated as--who writes orders? An LPN, although can be "in charge" in LTC, there is usually some RN who is available. Look at this patient's orders. There can be a "do not hospitalize" or some other order, that wouldn't necessitate a call to 911, however, would necessitate a call to the MD for further orders if any.

This place is attempting to cover their profit loss. Residents who are sent out of the facility is a financial loss to them. They can be "covered" by orders specific to not sending the patient out to the hospital. Even after falls. Sometimes that means switching to comfort care. You need to be sure that YOU have orders to back up what you are doing, and that you are documenting accordingly.

You need to have this discussion with the BON as well as your malpractice carrier. Although the director is acting as a CNA, they are still the director. And this is memory care, which is a component of assisted living, which doesn't mean medical care. If you search this site, you will find that there are RN's at assisted living who can provide no hands on care. (Doesn't make it right, however...)

Because this director is a business person, this is how they will see every encounter, medical or otherwise. Because this is not a medical facility, anyone can "give information" to the paramedics. And although you felt ethically bound to monitor this resident, assisted living is a whole different animal. And mostly, they can say that there's a nurse on 24/7 as a marketing tool.

I would get familiar with the policies of the facility. I would get familiar with the orders of each resident as far as not sending them out, if there's some sort of order set beyond medications.

And if this resident is a huge fall risk, and continues to be so, I would advocate for a higher level of care for this resident, before you give your notice.

If you find that you are the only licensed person in the entire organization, then I would run not walk. But please call the BN for guidance, once you have all of the information regarding the facility and the chain of command of the medical portion of the facility.

I find that assisted living is a tough place to attempt to practice. There's so much you should not do (due to the nature of the facility), the organization is weird...

Let us know how it goes.

[Red Kryptonite]

It gets said around here that the claim of a license being at risk is overused, and while that's probably true, I think in this case the concern is legit. A CNA supervising a nurse is the craziest thing I've ever heard of. I'm an experienced CNA, and a good one according to my coworkers, but when it comes to supervising a nurse? I don't know **** from Shinola, to quote my salty New England grandpa.

[nursebtanner]

If it feels shady it probably is. Check the Better Business Bureau website and look at their ratings etc. That will tell you any recent complaints filed on them. Call the board of nursing if you have to and always advocate for your patients and CYA..

[icuRNmaggie, BSN, RN]

If you ever find yourself in that position again, of being banished from the room by unqualified people, speak up and say

" The last time I checked you were not a nurse."

Let them fire you.

Then file for unemployment and I assure you you will receive it when you speak up about what led up to your wrongful termination.

You will sleep just fine knowing that you protected your patient.

[ca.as.lvn]

Update: Since my last post the facility had a CNA insert a suppository on a resident and when I informed the director that this is not within her scope of practice I was told that she has been here 8 years and knows the residents. Are you kidding me? Regardless, of how well she knows the residents her scope of practice does not allow her to perform such task. A resident got a large deep skin tear (3.75x3x2) on her arm by being forced to take a shower and restrained and Now I went into work this morning to find out that the night CNA pulled my meds for this morning and I am to pass them. I could not ethically work in this facility anymore. I resigned my position effective immediately due to unsafe environment for my liscensure. I am also drafting a complaint to my board and state in regards to the practices of the facility. I am not the type of person that quits. I have never done so in my life. However, being in this environment truly, I feel, was jeopardizing what I worked so hard to achieve and in good conscious could not work for a facility that puts more value on their own time and the bottom dollar than regulating a safe place for the elderly.

[caliotter3]

You did the right thing. Working at a job for eight years and "knowing" the resident, does not make it right for a CNA to perform an invasive procedure. You need to separately report that CNA to the certifying authority while you are busy writing up complaints. She is very well aware of the fact that she is not to perform invasive procedures and needs to be corrected by someone in authority.