After four years as an LPN with 11+yrs as a CNA; I really do not think of my self as a "new" nurse but I am always learning and do not know everything when it comes to my job as a floor nurse in a LTC/Sub-Acute/Rehab setting but I also feel extremely comfortable and ready for any..any..situation. That said, I met my match last night. I worked with, at first, a very nice older nurse...we will call her "Nurse J"... Several situations came up during our shift last night that involved my patients and one situation that involved another nurse's patients.
Situation #1...
During report, the reporting nurse informed me that one of my resident's was still up in her w/c and did not want to go to bed. She reported that when staff approached her and attempted to her put her bed, she would become very upset. I didnt think it was a major problem, and thought eventually she would go to bed. "Nurse J" told me immediatly after report that I should give the resident an Ativan so she would go to bed. Being a new nurse to the facility, I did not know my resident that well. So I looked in her chart and saw that she had an order for PRN Ativan for agitation and her last dose was the day before and that she rarely needed it. At that time, she was sitting in her w/c, eating a snack. She is alert with extreme confusion. But no agitation noted. So, I let her be. I advised the CNAs to offer her to go to bed when they do rounds. As the night went on, she was becoming more and more tired and started to hum. But refused to go to bed. "Nurse J" told her she "needed" to go to bed and the resident told her "No..you cant tell me what I need." She was never at any point agitated to the point she needed a PRN Ativan. I documented in nursing notes that she was refusing to go to bed when offered. At 3am, I had another resident situation and I was in that resident's room for about 25mins. When I came out, my resident was no longer up by the nurse's station. The CNA at the desk said the girls were putting her to bed. I figured she had just finally became tired and wanted to go to bed. "Nurse J" came out of the med room and said to me that she gave my patient her "night pill" and is finally going to bed and called her a "stubborn ol lady". I was floored. I asked her if she was agitated and "Nurse J" told me she was just annoying and wouldnt stop humming. Plus she needed to go to bed. I looked at the MAR and sure enough "Nurse J" gave her a PRN Ativan for agitation. Whenever a PRN is given, it must be charted what behavior was noted on the back of the PRN sheet and "Nurse J" charted she was a "7 out of 10" agitated and was "disrubpting" the unit. I asked her if she documented in progress notes why the med was given (as required) and she told me that no, that it was my resident that I needed to document. I told her I was not able to chart on something I did not see. I am all about giving someone a PRN med...WHEN THEY NEED IT!!! This resident did not !! You cannot force someone to go to bed. She refused. She has rights. It really ****** me off that "Nurse J", imho, stepped over her bounds and did that.
Situation #2
During report (again) , the reporting nurse told me that one of our older residents was in resp. distess and she wasnt sure what the next step was because she was a DNR. I asked if she called the doc and she said no. I asked why not and she said because she is a DNR. (really?!) I asked her if she knew what DNR means and she said yea..."do not do CPR.."(again really?!) I said ok..but we still treat. As she was talking, we were heading to the resident's room so I can assess the situation. She is a 96yr french speaking eldery lady with a hx of dementia, HTN, MI, COPD and DM. I entered the room and noted her laying flat in bed, and struggling to breath. She was on O2 via NC at 4L. I raised the head of bed up and put an extra pillow behind her. Her skin was cool and clamy. She was really answering my questions, just saying "yea". BP 98/50 HR 88 RR 24 and temp 98.9 .Lungs were noted with rhonci, sats were 85% with O2 at 4L via NC. I turned down the O2 to 2L. She had a PRN neb tx order for Q 4hrs. I asked the nurse when was the last neb tx and she stated she didnt know she had the order. ( smh at this point). So I gave her the PRN neb tx. Her sats improved to 95% but she was still, to me, in some sort of distress. Again, I really do not know the resident and do not know her baseline but something wasnt right with this resident. So I quickly phone the doctor and while waiting for the return call, the nurse and I finish report and the narc count. "Nurse J" had overheard all of this and went down to assess the resident herself. She came back and told me that is was "nothing" that she is "just dying" and there isnt really anything I could do because she is a DNR. I really didnt know what to say at that point. The doc called back and ordered stat labs, stat CXR, 1GM Rochephin Now, Duonebs every 4hrs and Z-Pack as directed to start in AM. Lab and xray results suggested pneumonia. MD updated. He stated he would be in first thing in the AM to see her and to call if any changes. "Nurse J " told me that I was making a big fuss over nothing, how I was just wasting my time.
Situation #3
A nurse came from the other unit and asked what she should do about a noted med omission. She had a resident that is AAOX3, c/o of severe pain and stated to her that the previous nurse did not give her any 9pm meds, including her sleeping pill and pain pills. When she did request something for pain, she was given Tylenol. The night nurse noted that the PM nurse signed out in the MAR that the meds were given but did not sign out in the NARC book that the NARCS were given and the counts for the meds were correct. It was clearly obvious the resident did not get her scheduled NARCS even the though the PM nurse signed the MAR. I told the night nurse its a med error and she needed to follow the facilities protocal when a med error occurs. At the very least, give the resident something for pain and let the supervisor know the morning. "Nurse J" stated to just medicate the drug seeker and mind your business. If you report her, that is tattletelling and nurses are too old to be a bunch of tattle tellers.
How in the world was that nurse able to give YOUR resident a narc??? Does she have access to your narcs? I would NOT work in a facility where someone else could get into my narcs and give them at will. Also, I am not at work to make friends, I'm there to take care of people who can not take care of themselves. If another nurse is making decisions that can cause harm to a resident I will absolutely report it. I know we all make mistakes but it looks like Nurse J is just plain neglectful/dangerous and should be reported. Just my opinion.
Where I am working, no one but the nurse assigned to the patients can get into the narcs that are in the locked box on the cart- only she has the key. That being said, I have one patient who has ativan prn by injection. And, that medication is in the fridge. And, both the nurses have a key to the fridge, so maybe this is how she accessed the med and gave it while the patient's nurse was with another resident.
With situation 3, just because she didn't sign out the narc but signed the MAR, does not mean for sure she didn't give the narc. I was shocked to find I had failed to sign out a narc I most definitely gave and had marked off the mar after I gave it. Sometimes an interruption happens and you forget to sign the narc sheet. I am also new. We caught it at shift change. And, I double checked the MAR to see that I had given it. I do NOT mark my meds off as given when I draw them up (normal meds). I mark them off after I return to the cart. It takes longer, but it's the 'three checks' and safer. Signing out a narc happens when you draw it up. This patient had two different ones at the same time, so I signed out one and not the other. It was a wake up call to slow down and be methodical.
I wonder why they didn't catch her not signing out a narc during the count at shift change, when she was still there to verify that the med had been given. I have had other nurses who have forgotten to sign the narc sheet and only realize it during the count (which is one reason we count, I'm sure!)
Just wanted to clarify... the PM nurse signed the MAR that she gave the scheduled NARC. But when the night nurse checked the NARC count book, the last initials were from the day nurse. The PM nurse did not give that med. As for nurse j, she had access to the narc box bc we share that cart.
Sharing the cart and narc box...what would they do if something went missing? How would they hold someone accountable- that's like multiple cashiers on the same register- what happens when it comes up short??
With the narcs, don't they count them together at shift change? Still fuzzy about the narc issue. Sorry.
I did have a nurse pull a fast one during a narc count. She read off the number I SHOULD see when I looked only at the actual bubble card with the narc, when in fact the number on the narc sheet read that there should be one more pill on the bubble card. (she kept one for herself)
This was the day I learned to look at the narc sheet to visualize the number written there during the count and not to take the word of the nurse only.
This may sound harsh. But, once you sign on for the shift after the count, you are verifying it was correct. And, if it is found to be incorrect later, you are the responsible one.
So, I don't do the quick count of the bubble cards anymore. This may aggravate some nurses at shift change, but so be it. My family really needs me to keep my license and my job more than they need me to make friends.
I figure if I do this at every shift change and with every nurse, then I am not singling anyone out as untrustworthy. And, i am sending the message that I am not an easy mark.
Yes they counted the NARCs at shift change together but the count was correct. The nurse did not pull the NARC that she signed she gave on the MAR. Which is a med error because its an omission. I do same as you mentioned,sign my MAR after giving the med and when I count with the other nurse, I look at the book and the bubble pack as we count. If I find a NARC not given , then I advise that nurse to correct it before I sign off for the cart.
Just wanted to update. I was called on Friday by staffing to cover the night shift for the weekend. When I got to work, I learned that I was covering for Nurse J. Turns out she got fired "after a number of noticable med errors." The DON had also posted a notice for a mandatory inservice to discuss med errors and patient rights. Rumors were also flying about other nurses that were either fired or suspended and the nurse giving me report informed me how I better make sure I have no holes in my MAR/TAR and make sure I double even trible check everything because management is cleaning house.
MotherRN
192 Posts
Where I am working, no one but the nurse assigned to the patients can get into the narcs that are in the locked box on the cart- only she has the key. That being said, I have one patient who has ativan prn by injection. And, that medication is in the fridge. And, both the nurses have a key to the fridge, so maybe this is how she accessed the med and gave it while the patient's nurse was with another resident.