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Discussion

pLEASE aDVIZE ME

Please help me, fellow nurses, I'm having an ethical dilemma.

I work for a government entity. We have an administrator with no clinical background; on top of that he has an apparent character disorder.

the Human Resources director, after being prompted by the Union (SEIU), took the unusual step of interviewing all employees to get a concensus of the serious problems we are having as an institution. To make a very long and convoluted story riff with political intrigue short, We are unable to provide adequate care for our community because we are short staffed and without leadership. Changes have been proposed. OK

We have one nurse, an LVN (me), and 3 part time psychiatrists.

After much anguish on my part there is a system in place where clients can obtain refills from me (or another Doc) if for some reason they are unable to meet with their MD in a timely fashion.To try to convince my character disordered boss that there was a need for this system took me MORE THAN 2 YEARS! Why? Because they "never did it that way before..." Yeah and it was a cluster #$%^. I met alot of resisitance.

We have 2 casemanagers in a county of just under 50K people.

One is a gem, a hard working woman with a masters degree in social work. The other was promoted from a secretarial position, has a highschool education. Her qualifications include having a husband who is an EMT and wants to become a doctor, and her supervisor (who was also a secretary until promoted by default) is the godmother of her oldest child.

Here's what happened:

1/7 /4 the case manager who shall remain unnamed phoned in a refill authorization to the pharmacy, stating the md had ok'd it. The meds included seroguel, depakote and ATIVAN. The pharmacy filled the reguest, but was only able to access payment for anything except the ativan. The tech called me the next day to try to get prior authorization to receive payment for the other 2 drugs. I attempted to do this but there was still a problem, so another day went by it is now fri the 9th I called the pharm.I asked the tech if the client had brought in an old 'script as he hadn't seen the Md since NOV. This is how all this came to my attention.

I immediately informed the MD of what happened. His response was one of anger and chagrin with an order for "no refills until seen " for the pt. The md told me to ask her to meet with him about this. (I literally had to grab him as he was heading out the door. I asked to be present for that meeting.Over the weekend I cant stop thinking about the whole thing.)

fri.afternoon I asked unnamed case manager what was the status of this pt. She told me she had talked to him on the phone on the day in question and that he needed meds. Nothing further. When I directly asked her if she phoned in a refill authorization she said "His Mom did" !!!!!!(I have documentation from thre pharmacy that she did it!)

I gave the pharmacy a ration of poop for doing what they did and not to do it again. There was no documentation in this clients chart that any case management contact had been made that day(or anything else for that matter.)I know she is LYING. I know she did not do this to try to help her client and that she did not understand the process, she did it in a sneaky way thinking no one would know and it would save her the hassle of a home visit and to try to get a difficult client in to see the md. Now this guy is in the community with a bottle of ativan and no other med and no support system cuz she doesnt understand what a casemanager is supposed to try to do! HOW ABOUT FIRST DO NO HARM!

I told my character diordered boss yesterday what happpened.The MD flaked and would not confront her. Told her to talk to me "because the pharmacy had accused her of something." No action has been taken at this point.

Am I wrong if I dont let this go? Are my own beliefs clouding the issue ( That she underqualified and lazy, and that her boss condones this type of behavior) Her boss ahs told me in the past "Youre in the wrong profession!" and "it's your job to authorize refills so we can bill" like some monkey could do it. Help me any and all feed back appreciated deeply.

Featured Replies

Are there any standing med orders? If not, are you getting authorization from the MD for the refills? If you have neither, then you should not be authorizing refills! And the case manager certainly should not.

Can we say "practicing medicine without a license?" Calling in an unauthorized refill on Ativan is not only that, it's violation of *federal* drug laws which can get one put in *the federal penitentary.* If the social worker's boss is aware that she's doing this, then the boss is also in violation and is also subject to prosecution. Violation of the controlled substances act is *not* something to play around with.

You need to be concerned about your license. I personally would get out of there as fast as possible. Out of concern for the patients, I'd also report the problems to whatever regulatory agency oversees this place.

ditto my thoughts exactly. You better stop any of these actions right now! or your license is in jeopardy.

I would once again check and make sure I was not named as the person who authorized the med refills. I would document all that has happened and keep the file under lock and key. I would transfer to another gov. job asap. I know you want the best for these guys. I assume they are vets and, heaven knows, we own them a lot, but I would not allow my license to be in danger one more day.

One valuable piece of advice I received form a nursing instructor when I started was "Generally when something feels wrong in Nursing the majority of the time it is". If you are feeling uncomfortable about something and feel it is unsafe. Stop what you are doing and document all you can as well clarify anything that you can. it is your right to refuse unsafe acts without fear of retaliation, in my opinion it is not your job to phone the pharmacy to order refills unless the doctor has written an order for refills.

  • Author

Yes, I have standing orders. I had to fight to get it into the chart.

I have to fight to get the MDs to sign each and every one in each and every record. I have been unable to convince my boss that we need a tracking system to make sure verbal orders get signed within the 5 day window that the clinic POLICY states should happen. No I do not practice medicine without a license I have been a nurse for 21 years and I know how to document document document!

I can not keep this clients record/chart to myself but I have made copies. I am not sure what to do next. I'm going to call attorney, but I'm not sure if I should call the DA or DMH( Dept of Mnetal Health) My experience with them arethat they are bumbling idiots and make each situation WORSE. I need advise on how much time I'm going to give my boss to take action. I'm still trying to decide if I'm over reacting too. The worse thing i can do is go off half- cocked. I need a level head and I dont have that right now.:(

  • Author

Well, the only advice I'm getting is to QUIT.

How is that going to stop this incompetent case manager?

How will this help my patients?

How will this help my co workers on the front lines?

I dont see quitting as an option

I'm well aware that my boss will retaliate against me for speaking up, he wants me to quit! He has attacked me before and has been unable to GetMe on anything because I have done nothing wrong (and I have a union.)

I have been tangling with this guy for awhile. I feel obligated to continue for the BIG PICTURE.

Oh well

I'll shut up now.

  • Experts

You can contact your state agency that licenses healthcare facilities -- there is usually a 1-800 "hot line" for complaints. (I am an RN investigator for that agency in my state.) Our agency (and probably all the similar agencies in all the states) maintains your confidentiality as much as possible when investigating (which means that we can't guarantee that the facility won't figure out on its own during the investigation who complained, but they sure won't hear it from US), and also allows you to make an anonymous complaint. When we get a complaint, we go into the facility and do a detailed investigation of whether the facility has broken any of the applicable state rules, and penalize them if they have. We also pass the complaint on to CMS (the Feds) if it looks like the facility is in serious violation of the _federal_ rules, and there may also be a FEDERAL investigation (which usually puts the fear of God in people, since we're now talking about whether you might lose your eligibility for Medicare & Medicaid money.)

All 50 states are now required (by the feds) to have an independent advocacy group for persons with disabilities, and they can be fairly aggressive about investigating on patients' behalf.

If you are concerned that the glitch at the pharmacy is more than just the pharmacist being innocently duped just this one time, you can report the pharmacist to the state Pharmacy board and they will investigate whether the pharmacist has violated any of the state pharmacy rules.

I'm guessing from your description that the slack case manager doesn't have any sort of license, but if she does, every healthcare profession has a licensing board in every state which also disciplines practitioners who have broken the rules.

All of these agencies would share your concern for the well-being of the patients, and they would certainly get the attention of the "powers that be" at the facility. But whether or not to report your own facility is a tough call. Best wishes with whatever you decide --

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