Biggirl71

Incident reports are important because they allow for trending of issues. So, if your patient is discovered to have something new; wound, abrasion, skin tear, etc. document it on an incident report. By doing so, you may enable the facility to purchase the needed equipment for good, safe patient care. If all skin issues are investigated and the investigation shows it's because the mattresses are old or bad, then you may find that they will purchase new mattresses. If you overwhelm them with documentation, you are not only advocating for your patients, you are advocating for your place of employment. If they arrive with the wound, careful documentation (not an incident report-unless you suspect abuse) keeps your facility from "owning" the wound. If they develop the wound while at your facility, an incident report is necessary.

I am a home health nurse and I work in and around Houston. I am here to tell you that I bring my husband with me on calls that are located in parts of town that I am uncomfortable in. I have arrived at some homes to be greeted by what appear to be gang members, in full-on gang attire, 15 of them sitting in the front yard drinking their 40's and not even conversing with me when I ask the question, "who is the patient?" I have NO problem bringing my husband along because in the end, anyone who inquires about my decision to do so, would probably have done the same thing. I DO NOT share personal information with my man about the patient, and I DO NOT bring him in the house with me. A HIPAA investigation would be the last thing I was concerned with in the event something happened. I will also say that generally, when people see I am in scrubs, I get respect because they know I am there to help someone. I also do not carry myself as a victim and I keep my eyes and ear open. If I ever felt unsafe about entering someones home, I wouldn't. Bottom line, HIPAA rules state that private information should be kept confidential unless the person has a NEED to know it. If I am in an unsafe situation, my husband then has a NEED to know. Good luck to you!

I use reverse psychology on patients over a certain age. I say to them, "Who is going to do these things for you when you are discharged home?" When they can't answer the question, I say to them, "We better start practicing these things now because you don't want to be discharged to a nursing home; if the treatment team finds out that you are struggling with toileting yourself, they are going to start looking at alternative discharge plans." Every time I have had this talk with someone, the game changes. I believe the problem (most of the time) is that the patient is lonely and wants someone to spend time with them. I have seen patients in the hospital for up to a month with no visitors or phone calls and during their stay I find out they have 6 kids that haven't bothered checking on them. Sad. I say whatever works. The truth is, if they are capable, then they MUST do it themselves. The goal is to keep our patients as close to their normal level of autonomy as possible; we want to maintain their quality of life as much as we can.

I see the charge nurse as a resource not an extra person to do the work for all of those in her charge. The truth is, as nurses, we should be autonomous but also know when to ask questions. I would not expect my charge nurse to do something for me but I would expect her to help me with my questions/concerns. I think the use of a charge nurse depends on the type of floor; how busy it is, how many nurses are working, how many problems there have been, etc. If using a house supervisor in place of a charge nurse works then so be it. If it happens to be a 300+ bed facility then I would wonder how effective a house supervisor would be in addressing the concerns of every nurse during a shift. Hospitals try to do what is most cost effective. That doesn't always mean it's is necessarily the BEST practice but if they can get away with fewer staff members, then they will. I personally have been in the charge position in one form or another for years and my feeling is, a nurse who comes to me with questions, is looking for an answer, if he/she is expecting me to go carry out her duties then he/she is sadly mistaken. That is not to say that I don't help. There are thousands of times that I have tag-teamed tasks but to have the expectation that I would stop what I am doing to take over the care of their patients is presumptive. I am paid to do one job; I get one salary. Having said all of that, I would NEVER let a patient go without. There is the rare occasion that I have assumed responsibility for a patient load because the nurse had to leave. We just do what we have to do to get the job done. I have the opinion that it's better to help everyone knock out what needs to get done. I am all about team work. I have put many hundreds of miles on my shoes over the years and I will gladly continue. . .there is real satisfaction for me in helping people; whether it's a patient or the nurse caring for them.

Everything that I am reading these days is leaning toward the BSN as entry level for RN's. Because of the wicked nursing shortage (right now ~100,000) and the expected increase (~800,000) over the next decade, hospitals will demand that the RN's be educated enough to start to handle more responsibility. I have said it before that years ago, when you went to the doctor, he was the one that gave you the shot and dressed your wounds. Eventually, those responsibilities were given to the nurses. I feel like that is where we are headed again. Nurses will take on more "medical" stuff, mid-level practitioners (NP's and PA's) will start to do more, and physician's will be responsible for the oversight of all of it. CNA or techs will take over a lot of what nurses do day to day. I think the best way to go is get your BSN if you have the opportunity to. Don't bother with the ADN program. Although, I am currently about to graduate from an RN-BSN program at UT, I have consistently earned good money as an ADN. The other thing is, I never turned down an opportunity to learn something new and take on more responsibility. I have been in management or supervisory positions since I was 5 months out of school. The trick is, I have maintained skills because I take the time to see patients and perform tasks that keep me marketable. I practice EKG strips, IV starts, etc. I also take the time to do training so I can get certificates. I have taken the time to build up my resume and after 12 years as an ADN RN, I am pretty marketable. Do it and you won't regret it, I promise!

Who knows, you may fall in love with your new position and not want to leave. . .just a thought.

I would also like to add that anyone who practices above board would not have issue with counting. . .it just makes me wonder about these nurses. . .

I would stick to your guns and training on this one. Count, each and every time you take responsibility for the cart. Who cares what everyone thinks of you. The truth is, you're there to make a living not friends! I agree that it is illegal and against best practice to just take over a cart without knowing if its contents are correct. You knew that right away. I wish you luck!

I am speaking to you as a nurse, not an instructor. I have a vivid memory of the first few days of class where the instructors talked heavily about "accountability." That lesson has resonated with me for 13 years! The instructors spoke about nurses who make mistakes and immediately blame others for it (pharmacy, physicians, etc.). A stand-up person, especially a nurse, will say, "I did it, I made a mistake." The nurse will show remorse, and work hard to repair the damage done. These students need a lesson in accountability. They need to understand that they will be part of a PROFESSION that demands integrity and accountability. They will be responsible for people's lives. They will have to answer to their superiors, including physicians and sometimes families, about their actions. They need to understand the weight of the PROFESSION they have chosen. My advice is. . .do a Google search of "accountability" and put a lesson together that addresses all of your issues under the guise of the "accountability" lesson. Have each of your students sign that they have read/followed along and they understand what you are teaching. Maybe even have them do quiz. I wish you luck. It's sad to think that all of these precious spots in nursing programs are being taken up by ingrates!

I work for a home health agency in The Woodlands and a LOT of the referrals we get are for one-time assessments for insurance companies. The assessments are MMSE's for claims on long-term insurance policies. The other large part of our work is for round-the-clock care of patients (these are our cash cases). The RN oversees the CNA's so they can be checked off for med pass and other tasks that the RN delegates. Keep up the hard work. It will pay off. I have 4 patients that I see weekly or more. 2 of them are pedi infusion cases that pay me $60. The other 2 are elderly 24/7 cases that I pack the meds for. Some plastic surgeons actually have nurses in their office that will go home with their patients and provide the initial care at discharge. Just keep going out and getting your name into the market. The other places you may want to focus on are LTAC's, Rehabs, Acute Care hospitals (of course), Pedi offices, Internal Med offices, etc. Good luck and if you have any other questions, you can contact me at [email protected]. Thanks. . .

The thing that jumped out at me was the hx of ETOH. Usually, the patient will tell you they have a "couple drinks" and that generally means many more! I would be concerned that the b/p is going up day by day because the patient is NOT drinking. This is usually a sign of DT's. Withdrawing from ETOH is the only substance that can cause a life-threatening condition. ETOH patients who DT can have arhythmias that can cause an MI. You did the right thing by calling the MD regardless of the time of day. Every patient is different so it is impossible to say that a specific number could cause a stroke. One never knows. Calling the MD to clarify meds and treatment for this patient was correct. MD's need to get over themselves and just address the issue without making nurses feel bad for calling them. Honestly, if he were asked which he'd prefer, answering the phone at 2 AM or sitting on a stand answering to a prosecutor, I am sure he'd prefer the phone call that woke him up. I think you did the right thing.

First things first. Arizona is a "right-to-work state." This means that an employer can fire you for any reason and without union protection, you are at their mercy. If there is an Accudose or Pyxis machine dispensing the drugs, they can run a report to see the exact number of narcotics you pulled including all of your overrides. They may not accuse you of actually consuming the drugs but they can accuse you of diversion. So in essence they don't have to prove that you actually are physically taking for yourself, they can accuse you of taking them for whatever reason, "diversion." I would hold off on any action until I hear the outcome of the facilities' investigation. Once you get that answer, my advice is to take a drug screen ASAP through a reputable lab and keep your documentation from that. Then, hire an attorney that specializes in professionals with a license. Yes, they are expensive but if it means saving your livelihood then it's worth every penny. I would also research on the Arizona State Board of Nursing the CANDO program. Read everything you can find and get yourself ready to participate. The fact is, your employer already suspects you of wrong-doing and they will probably refer you to this program. These programs, offered to nurses in 25 states, are expensive and arduous but participating in them will save your license. Read, read, read. . .education is freedom! I know you are freaking out and you have a terrible feeling in the pit of your stomach but arming yourself with information is the way out of this. All nurses need to be aware that handling narcotics is serious and watched very closely. Even if you are not guilty of what they're accusing you of, it would be irresponsible for the hospital to ignore the issue. What if you are guilty and they just ignored it, if a mistake occurs while a patient is in your care, the patient could sue the hospital and win because they were aware of a "potential problem" that they failed to address. Please let us know what happens. I am thinking about you!

Correct. Water-based is the way to go.

OK, I am employed part-time with a Home Health Agency in Texas and I am considered the Alternate Administrator (on paper). The very little I know is as follows: 1. You can design your own forms with your logo at the top. You can use Word to get this done. At minimum you'll need: Physician order form Blank nurse's narrative notes IV Infusion notes (make sure to include spaces for vital signs pre and post, IV start information, medication lot# and expiration, etc) Time Sheets for your providers with a place for the patient to sign Make sure you have a care plan for each patient which includes the nurses recommendation for length of treatment (this information will generally come from the physician order). You should probably come up with a form that documents the teaching of the patient or spouse/parent in doing a particular treatment. I find that I do a lot of wound care and infusion treatments that I must teach to the family. It is nice to have the family member sign off on what they've learned and agree to do it in writing. 2. As far as pay rates, they vary and I agree with the comment above that Maxim would be bottom of the pay scale. Generally, if you have a high acuity patient (for example, a wound vac pt or infusion pt.), you will pay the RN more for the higher skills. If the nurse is going in weekly to set up meds for a patient and do an assessment, $30 sounds right. If it's a CNA providing 24/7 care, $10-12. LVN's are probably at $20. Make sure you pay per visit for the nursing skills. If you agree to hourly, it can get costly. BTW, as your business grows, you can make deals with your nurses to pay hourly for difficult-to- staff patients. If you are billing Medicare for services, they have a whole slew of requirements that you can obtain by calling Medicare. Your record keeping must be meticulous. I know there are agencies that specialize in billing for you. They will do both commercial and Medicare/Medicaid. You will have to do your research. You can also market your business as cash only. When you write up your contracts, make sure to include things like nurse phone calls. People forget that their time is worth money and I personally have spent many hours (depending on the complexity of the case) on the phone with physicians, pharmacies, and patients. So if you tell your nurse she gets $30 per visit, work something out for her hourly time spent doing other things. If you intend on becoming JAHCO accredited, do a Google search of what is required by JAHCO for Home Health Agencies 3. Marketing It is my recommendation that you spend time deciding what exactly you are willing to provide. If you are interested in pediatric infusions, you must come up with a brochure that targets your pediatric audience. Again, Google some ideas. Then make sure you drop them, your business cards, an some sort of food off at every pediatric office in your area. If you are interested in post-op care, make your brochure and be sure to include plastic surgery! Remember, plastics is generally CASH. Put detailed info about the services that target that audience. Be sure to hit every office in your area and take treats! As many items as you can afford with your company info on them, will pay off! Make up folders for physician offices that include copies of your physician orders, brochures outlining your services, etc. If you have a friend willing to do some marketing for you, jump on it. I hate to say it but the cuter she is, the better your chance. Unfortunately, the male dominated physician world likes to visit with the cute ones. The whole idea is to saturate the area with your name and the wonderful services you can provide. 4. Make sure you keep a binder for each patient in the office. If you are running the agency from your home, dedicate a room to your business so you can have everything you need in one place. The binder should include all orders, care plans, contract, all original nurses notes, medication lists, a face sheet of sorts with contact info, address, etc. Time sheets should be kept electronically in your computer and stored in the employees binder. Be sure to get diagnosis codes from the physician for billing purposes. Fax the orders to the physician office with a cover sheet as mentioned above that includes a time frame for returning the signed order. I hope this info helps. I know it's a lot of info and it's kinda scattered but hopefully it's useful to you. If you have any other questions, please let me know. Can I ask which area in Texas you are located? Good luck to you!

Texas is a right to work state and they are totally against unions. However, I am from Wilmington, Delaware and I come from a union-heavy family so I believe in the need for unions. When you are in a right to work state that does not like unions, you run the risk of being terminated if your employer finds out you have joined a union. The truth is, in Texas if your employer doesn't like the fact that you drive a red car, they can fire you. So needless to say, any union activity would have to be on the down-low and then in the end, having joined a union may not pay off the way they promise because they aren't allowed in. A union rep cannot just walk into a hospital and start recruiting members. Hospitals have the right to ask them to leave because they do not accept outside vendors. Having said all of that, my husband is a life-long Teamster and when he moved to Texas from Detroit, he continued his union membership. At that point, he had the option to stop paying his union dues and continue to reap the rewards of union membership. Although he continues to pay his dues, some of his co-workers have stopped. Because Texas is a right to work state, they do not enforce the union dues. I hope that clears up some of your questions. I have very limited knowledge of nursing unions because they are not readily available to me. Maybe you could fill me in on how they work. . .? Thanks. . .