RNinSoCal

I hope they are paying for your housing. I worked at Sequoia Hospital (which is 20 minutes from Stanford) in 2008 and made 57 an hour as a staff nurse on med/surg. My rent was 1625 per month for a tiny 1 bedroom apt though.

You are misunderstanding. They are doing this on the regular order pages outside of the monthly printed orders forms-on the hand written daily order sheets. The regular MD order sheets look like a confused mess with orders crossed out everywhere. I have never seen anything like it. If it was just correcting the monthly orders I wouldn't be asking this question.

Hello educators, I have run into a problem with nurses crossing out MD orders that have been changed or discontinued at a LTC facility. For example an order written on the MD order sheet reads "6/15/10 Tylenol 650 mg po Q 6 hours prn for mild pain Dr. Knowitall" If the MD writes new order "6/25/10 DC previous Tylenol order. Tylenol 325 mg po Q 6 hours prn for mild pain Dr. Knowitall" the nurses are crossing out the order on 6/15/10 on the MD order sheet and writing DC'd next to it. I hope that was a clear example. I tried to tell the DON that the order on the MAR needs to be crossed out and re-written but never the order on the MD order sheet. She thinks that this practice is OK. I have been looking for some kind of book or article that would give concrete proof that this is poor nursing practice so that I can pass it along to the DON. Does anyone have a resource or reference that I could use to help improve the nurses practice with MD orders? Thanks in advance for any assistance.

I have not been able to find any professional nursing or medical texts/articles on orders charting. I wonder if there is a standard for orders that I would be able to bring to the nurses as evidence. They don't know me well enough to know my years of experience with hospital and JCAHO orders compliance and some outside documentation would be useful. If anyone has a book or article to recommend I would appreciate it.

I agree, it makes the original order appear to be invalid. It also could look like nurses are trying to falsify medical records when viewed from a legal standpoint. I have to say something to some of the nurses who are doing it. I already talked to DON and she thinks it is OK. I have no power over this situation. I have been entering the MD orders for monthly order printouts for 2 months and there have been no errors.

OK, here is what they are doing: MD order on regular order sheet " 6/15/10 Tylenol 650 mg po q 4 hours prn mild pain Dr. Knowitall" The nurse receives new telephone order from MD on 6/24/10 for Tylenol 325 mg q 4 instead of 650. She goes back to original order on 6/15/10draws a line through and writes changed then writes new/changed order. I do not understand why anyone whould draw a line through an older order on a regular order sheet. The new order is the valid one and the nurse needs to change the MAR not the MD order sheet. This is not just the printed re-cap it is happening on. I know it is bad nursing practice but as a previous poster said feathers will ruffle if I try to tell DON what to do. CHW (former employer) would have had a cow over this kind of nursing practice. I am happily doing MDS forms today.

Thanks for responding! I thought it was wrong too. I asked the DON if it was done on all order pages or just the monthly printout and she said on any order sheet! State should have fun with her:eek: I am just the alternate MDS nurse, not in charge of pt care at all. Maybe she will ask someone since I questioned it.

Hello all, I have not posted here before. Switched to MDS nurse (LTC) from med/surg for a change of pace. My feet still hurt from all the years of med/surg!! Not that LTC nursing is easier, just MDS work. I am helping to enter MD orders for the monthly physician order printouts (since the nurses here do not know how to use a computer and the medical records person is new). I noticed that the nurses are crossing out MD orders when an order is changed or DC'd. It is so strange to me. It seems wrong to cross out an MD order. In acute we would just write the DC or change in order and leave the older orders alone. Is this a common thing in LTC or just a totally wrong practice at this facility??? I am learning this is a different world from acute. It IS a nice change of pace though. Thanks for any input.

Sequoia has a great reputation all around and the pay is great for experienced nurses. It is worth a try to see if they are hiring, you can apply online.

I recently turned down chemo certification classes at my facility because there are no benefits and many draw backs. There is no pay increase for chemo cert where I work. Nurses who are chemo certified are asked to float or travel to other units to provide chemo with no compensation. We do not have enough certified nurses on the floors to be safe (our infusion center has plenty due to the 9-5 hours M-Fri, the floors have few) There are dangers involved with contact to chemo that I am not willing to risk until my uterus is non-functional. The benefits have to outweigh the costs for me to change my mind. My facility also has no extra pay for ACLS, PALS, or any specialty certification in any area. Union hospitals have good pay, but only one pay scale regardless of the extra letters after RN.

I like omnicell for 2 reasons: You don't have to count your narcotics The omni machines are bigger so more meds can be stored in them. We just switched from pyxis to omni. We used to have 2 pyxis on the unit and we were constantly running between the 2 machines to pull meds (large med/surg, ortho, oncology unit). Now the 2 omnis have the exact same meds stocked so I don't have to walk to 2 machines and wait in line to pull meds for each pt. I do have to say that I don't like that our omnis don't prompt for a waste co-sign so we have to remember to waste. The pyxis would prompt us and show a cosign screen for waste without additional steps. The bottom line is, having no dispensing machine at all on a med surg unit is hell. I remember the time before them and it was tedious, time consuming and there were always missing meds that pharmacy took hours to deliver.

Cg88, I know your pain. My mother was diagnosed with cancer 6 week after I graduated from nursing school and I moved home with my family until she died. This was 10 years ago. I needed time to grieve and recuperate after the stress of her death. I took the NCLEX 1 year after I graduated and passed at 75 questions the first time I took it. I bought 2 NCLEX study guides and took all of the tests in them. I also re-read the chapter summaries in ALL of my nursing text books and answered the questions at the end of each section of the textbooks. It can be done with discipline, I am proof of that. I did have to take an RN refresher course before a hospital would hire me because I did home health first after passing the NCLEX. 10 years later I am thriving as a med/surg nurse and I love my job. You can do it if you set your mind to it. The textbooks and study guides contain what you need to pass. You have to buckle down and study and you can pass without returning to school. I hope I have calmed your anxiety. I remember I was an anxious panicky wreck until I found out that I passed. You can do it!!!!! PS I never took Kaplan but many people say it helps.

I agree with the other posters, that situation should not have happened to you or your patient. I would have refused to leave my other patients to take a pt anywhere for longer than 15 minutes. There should be charge nurses who have no pt assignment and a nurse supervisor to handle critical situations on a med/surg floor. I know that what "should happen" is not what does happen, but no new nurse should be put in that type of situation alone. In my 5 years of hospital nursing I have never sent a pt to ER. I have sent pts to tele or ICU when they go bad, but never back to ER. The ER Doc comes up to the floor if a MET team ( Medical Emergency team) call is made, not the other way around. Sounds like a dysfunctional workplace to me. Watch out for your license!!

If California goes 4:1 on med/surg you can bet it will be primary care with no CNAs. I dread the day I have to work without help. The CNAs on my unit are worth their weight in gold. I would rather have 6 patients with help than 4 patients alone any day.

The ratios are true in California for hospitals, but not for nursing homes and subacute care centers. I f you want to work in California look for union hospitals. My hospital is contracted with CNA and there are consequences for going over the ratio. We are 5:1 on med/surg and how we deal with going over ratio is filing a "No break no lunch" form. The hospital has to pay us each 2 hours of penalty pay for getting no break/no lunch due to being over ratio. It costs the same for the hospital as having 1 or 2 more nurses on shift depending on the census. Needless to say, we are rarely over ratio on my unit. In a non-union hospital there are no gaurantees on ratios. I used to work for a non-union hospital in Los Angeles as recently as 2005 and the "ratio" was 5 patients of my own plus covering for up to 3 patients with an LVN. That means I really had 8 patients to chart on, take orders on, administer IV medications, update careplans on and speak to family members about. California is a great place to work if you find the right hospital. You really can't beat the pay. Best of luck.