new grad RN reporting patient rights violation..

  1. Hi guys,
    I wanted to get your opinion on this. I just took my boards in June and was hired on a sub-acute rehab floor in a large hospital. one of my patients has been there for months and is post-CVA, he also recently found out he has late stage cancer. this patient is in pain all the time (prescribed narcotics have thus far not controlled his pain), and because of the stroke, he sometimes has a difficult time understanding what is going on. He often is non-compliant and refuses medications and treatments, and will only let certain staff come near him. Yesterday I was giving report to the nurse on the next shift. I told him that this patient had a routine bladder scan ordered because of PVR, however he refused the scan and became combative. his provider was notified of this and did not give orders to proceed with the scan. the nurse told me that the refusal wasn't an excuse, and I need to force him to comply. he pointed to my lack of nursing experience for not forcing him to comply. I have also overheard that this nurse and a couple of others frequently hold him down against his will to get routine procedures done (nothing emergent).

    I had huge issues with what he said/did. We are a restraint-free facility, and in the patient rights, it says that physically forcing a patient into something against their will is assault. I decided to go to my nurse manager with it, not just to cover my butt, but also because it stung to hear that a patient I've gotten to know and like, who is at the end of his journey and in pain, is being treated poorly. My manager didn't seem overly concerned, and said she would talk to the specific nurse. I'm afraid I've poisoned the well- this nurse is my new charge nurse once I switch to 2nd shift at the end of the month.

    How would you have handled this situation? Is there anything I could have done differently? I'm wondering how to approach the situation if it backfires on me, and the other nurse finds out I blew the whistle. any advice is greatly appreciated, I am still learning (I've been a working RN for 3 weeks) and am open to suggestions.
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    About pkateRN

    Joined: Jul '12; Posts: 21; Likes: 21


  3. by   Orange Tree
    There is some gray area. From what you say, the patient doesn't sound competent to make his own least at some times in some cases. I would have re approached the patient after allowing him some time to cool down, but continued to attempt to scan him. Gentle restraint can be appropriate in some cases. What does his family think?
  4. by   RN1145
    I would have attempted a second, third and fourth time and documented in my notes to cover my tail and to be able to pass on in report that u did attempt 4 + times. It's difficult dealing with confused patients but holding them down is not in my scope of practice as an RN. I work in a ICU stepdown unit so patient's are usually confused. If it's non emergent, I would try again later. Confused patients will hurt you & then it's all your fault because u got yourself hurt. Get a witness.....someone to assist u with the bladder scanning and use judgement on what to do. compare old bladder scans to current ones to see what his norm is.
  5. by   pkateRN
    Thank you for the replies. I should have made my original post clearer. This patient will usually take his medications for me, and if he doesn't, I go back and ask him a few times. He has issues with certain staff members- will only let specific people (me, charge nurse, and one or two other nurses) go near him. he generally refuses for other people, especially when they tell him to do things instead of asking. When he refuses for other staff on days, they grab one of us to assist. They are very stringent about patient refusals here- one of our NAs was just suspended for disconnecting a tube feed after he told her no and to get away, and for trying to force him to get out of bed.
  6. by   jadelpn
    If the patient is not competent to make his own decisions, then that needs to be assessed, and get social work involved. As well as hospice, as if he has late stage cancer, his pain is an issue that needs to be dealt with. (Patches are good alternatives and allow for less interventions) CVA's are tricky things, and can cause significant MS changes. Late stage cancer can metastisize, (<---and I am sure I spelt that wrong) but in any event, it can certainly make someone worse as far as being combative and not understanding what it going on--and the brain is often a place to have mets.

    With all that being said, it could be that this man is well aware that he is dying, and well aware of everything that is going on-- and because of expressive aphasia(which he may or may not have in r/t his stroke) can't communicate that effectively, therefore, he is telling you "NO" the only way he can.

    This patient, in my opinion, needs a care conference to address his plan for treatment. Pain control, a foley (?) for comfort, comfort care if that is what the patient's wishes are, that type of thing. Involve him, his health care proxy, family. To continue to bladder scan or other interventions that are not working and causing the patient acute distress is disheartening. The goal, at this point I would think, would be peaceful, calm, pain free.

    If the patient wants all treatments, is getting treatment for his cancer, if the patient wants "everything" done, then speech language needs to be consulted to see exactly where the patient is at as far as communication. Should the family want "everything done" then perhaps he needs to be transferred to an alternate level of care if the patient's condition may require restraints, and you are a restraint free facility--which seems overly cruel and unusual punishment, however, if patient and family are not in a place to accept the possibility of this man's impending death, then the only thing that you can do is follow the wishes of the patient, or in the case of patient not being competent, his health care proxy he chose to make decisions for him.

    In this instance, everyone needs to be on the same page, and the goal needs to be clear. And the only way to do that is to have a conference to address these issues.
  7. by   pkateRN
    update: raising this issue to my manager went nowhere. in addition, the patient's daughter is his legal guardian and was called into a family meeting where she decided that he is to have surgery in order to remove 2/3 of his tongue. he will also be trached. I read the PA note, in which the PA stated she had doubts he understood what he was about to go through and will need to be sedated/restrained after the surgery for an extended period of time. he hasn't had the surgery yet, but his newest thing is to make a gun with his fingers, pull the trigger and act like he is blowing his head off. even the nurses involved in forcing his care are horrified at how all of this is turning out for him.
  8. by   jadelpn
    This is a really unfortunate turn of events.
    Where his daughter is his legal guardian, then the court decided to make her so to look out for her father's interests, and adults usually don't have guardians unless deemed incompetent to begin with. So this was not his choice in who his decision maker should/would be.
    I would again ask the social worker if it appropriate to have a final meeting to talk about what the goal in removing part of the patient's tounge and traching the patient will do to improve a quality of life when one is dying of cancer. Where the patient is now making suicidal gestures, this would be appropriate to again get social work involved. Where you previously stated you are a restraint free facility, he would have to be moved to a facility that is not. Seems like the kindest thing to do for this patient is to control that pain, and if it means altering his level of conciousness to make it so he is constantly not distressed could be a viable option for the care team to speak with the daughter about. When he is moved (as the PA stated that the patient would have to be restrained for an extended period) the new doctor taking care of him could make alternate plans, and decline to operate on this patient. Which would be an ethical choice.
    Perhaps your manager's thought process is that you all won't be involved in the continuing care of this patient due to his need for restraints. But this is something that could be a case review, brought before your board of ethics, adminstration beyond your manager.
    You never know when a patient such as this will be brought before you again. And you still have the patient in your care until such time as a transfer is ordered. It is an ideal time to review a plan of care pertainent to your facility and right now. It is hard to explain why it is that a patient has 24 hours of complete distress and unresolved pain. So make sure you document really, really well.
  9. by   AtivanIM
    In our acute psychiatric facility we cannot make someone take their medications regardless of how delusional they are unless:
    1. They are court ordered or revoked court ordered
    2. They are actively hurting themselves or another patient and the MD must be called for an emergency NOW IM order first
    I believe in your case, the charge nurse made the judgement of the patient being mentally incompetent and should have been held down for the bladder scan that the MD had told you to disregard. Also, I'm assuming that a nurse can not independently deem a patient mentally incompetent in your facility and suggested you force orders.
    I'm pretty new myself and very new to my facility. I have been caught in a few political situations and have tried my best to stay under the radar, but occassionally I HAVE to say something, because in the end it is MY patient. Charts will get reviewed, and as nurses, we ultimately need to advocate for our patients.
    If you work with that nurse as your direct supervisor in the future, ask for their advice, but call the MD and say something to the effect of: Hello Dr. _____, this is AtivanIM on the ______ unit. I had talked to you earlier about the bladder scan on Mr. _____ in room _____. He is now also refusing all medications, in addition to the bladder scan you decided was not necessary earlier this evening. The reason I'm calling is, I've talked to the charge nurse about the situation with his refusal of medications and he/she feels that the patient is decompensating, may be mentally incompetent, and the medications are necessary. I would like to reclarify Mr._______'s orders with you quickly to ensure we are following the orders correctly.
    He is currently taking ---important meds and dosage--- (and list the names of the non-emergent medications.) Would you like to order any of these medications IV or IM since he is refusing all PO medications or would you like to wait until the morning when you can reasses Mr.______ to make this determination?
    :::Wait for MD orders:::
    Read back orders, then chart either the addition of new routes of medications and administer or the order to hold the medications until the reassessment by the MD during morning rounds....Forcefully giving medications or withholding all medications should be a MD's order.
    Ask your charge for advice but not for permission. Your job, your licence.
    In addition, chart what time the charge nurse was notified (but do not flame, there is a good chance that they may "review" your notes), when the MD was notified, and a basic description of his orders in addition to the nursing interventions.
    One more word of advice, when you call the MD, quickly say everything you need to, only leaving room for an "mmmmmhm" until you give a chance for orders. On night shift, the doc is usually more than happy to take your recommendation on the treatment so they can go back to sleep
    Good luck to you!