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. . .

My understanding of forgiveness is that it is a decision, not a feeling. So when one forgives, it is a conscious decision. Forgiveness is not something that one will necessarily feel. So, we can forgive but we may never forget what happened to us. I think the biggest trick with forgiving someone is that once we say "I forgive you" we can never throw what happened in someone's face. If you decide to forgive someone, you have to let it go without feeling compelled to remind that person what they did to us. On the same note, we don't have to forget what happened. As a matter of fact, once you forgive someone, I would imagine that you will be on guard with that person forever. It's kinda like: Burn me once, shame on you; burn me twice, shame on me. I too have heard Oprah refer to it that way and I think that's pretty accurate. I wish you luck!

Mouth care is a pet peeve of mine as a nurse. I would use anything available including Vitamin E, surgi-lube (which is the same as KY), some of the oral swab kits come with a tube of lip goo that sometimes looks like lotion. If you are working with patients that have family involvement, you can come up with a list of items that the patient may need during their care. This list can include things like: lip balm (Chapstick, etc), lotion, eye drops, powder, etc. This not only gets the patient what they need, it also allows the family to contribute at a time they often feel powerless. This is true for those in the hospital and those on hospice. Good luck to you!

I am so sorry this nurse is learning the hard way that the rules are in place for a reason. The truth is, anyone can report us to the board. It could have been one of her co-workers, her manager, the family, and even the physician. I have been a nurse for 12 years and I have NEVER written an order that was not given to me directly. There are even physicians that I will put on speaker phone so I have another nurse witness because they have histories of claiming they didn't give the order. With something like end-of-life, you can't play around. A quick call to the physician to say, "look, the family arrived early and they have decided that they are ready, can I change the time on the order?" By doing that, you cover yourself and you do the physician a courtesy by letting him/her know what's happening. I hope it works out for your friend. Those remediation classes and answering to the board are expensive and arduous but if it saves her livelihood, then so be it. After all of this, I guarantee, this nurse will ALWAYS call the physician for her orders.

After reading all of the posts, I am still coming back to the issue that you are taking out so many narcotics that it flagged you in the system. Who worked in your position before you? Did they have the same number of patients with the same narcotic needs? The hospital has a responsibility to report because what if you really were diverting/using? The truth is, your problem doesn't sound like it's gonna go away. If I were you, I would be expecting the registered letter in the mail from TPAPN. In order for the hospital to turn you in, they have to have proof. The proof is the report that the Accudose or Pyxis prints out. All overrides will be listed too. You could hire an attorney to fight the issue but because you are positive for opiates and you withdrew what I am guessing are high numbers of narcotics, you will go broke in defending yourself and the outcome will be the same; you will have to complete the TPAPN program in order to save your license. TPAPN is a 2 year program that only 1/3 of those enrolled complete. It is an expensive, arduous program but if you have a problem, this is the best answer to keeping your license. I am estimating that within 2-3 weeks of your termination, you will get the TPAPN letter. The best advice I can give is to sign up and go for it. You can go find another job but the consult to TPAPN will follow you until you complete it. If you sign up to do the program, they will never put any "formal charges" on the website. If you opt to fight or ignore the TPAPN letter, before long when you sign on to the website, formal charges will appear and getting into TPAPN at that time will only happen because you have sat in front of the board and tried to defend yourself. When potential employers log on to confirm your license, they will see the pending charges and you won't get hired. If you would like to talk privately, send me an e-mail: [email protected]. I am a manager at a facility that is TPAPN friendly so I know a TON about the program. Usually nurses who enter the program find it next to impossible to find a job. We have had 3 successful TPAPN completions in the last 2 years. I hope this all works out for you and your former employer accepts your explanation but my gut is telling me that they won't. Brace yourself. It is a difficult position to be in but it is possible to get through. I will be thinking about you!

I am not a "bitter dried up nurse that needs to retire" but I am a nursing PROFESSIONAL that commands respect because I have spent my entire adult life educating myself on how to best take care of those in need of my services. Gone are the days that when the physicians walked on to the floor, all the nurses stood up! Gone are the days of back rubs! Gone are the days that nurses were expected to wear white and nursing caps, fully intended to make us submissive. The bottom line is, I am a nurse. I provide the care that I have been trained to deliver. There is nothing wrong with making patients comfortable and showing grace and compassion for someone stuck in a hospital trying to recover from whatever it is that has totally altered their life. Don't get me wrong, I disagree with the whole "customer service" model in a hospital. The problem is that illness is a big business that just so happens to have buttered my bread for 12 years. Gone are the days that patients didn't have rights. They were told what to do to get better and they did it because back then, noncompliance wasn't tolerated. I am not slinging hash at Denny's, I am an educated PROFESSIONAL. I act that way and in return, I am treated that way. If anyone sees the mistreatment of a patient (not a client or consumer but a PATIENT), verbal, physical, financial or otherwise, it is their responsibility to report it. When they get enough complaints about someone, they will address the problem. Again, nursing is a PROFESSION and to expect to walk into a facility and weed out the bad seeds in cowboy fashion is unrealistic. Follow the chain and demand results. When we are practicing above board, no one can tear us down! While I am at it, I think I will also comment about how nurses never seem to have each other's back. For example, if I meet a nurse that is verbally abusive or abrupt with his/her patients, I have no problem asking him/her what's going on. The truth is, people act that way because others let them. If you PROFESSIONALLY raise the question and call them on their behavior, then they somehow loose their momentum and "getting away with it" is no longer possible. Just a few of my thoughts. . .

What happened? You will find out soon enough. If it is for practice issues, it may take several weeks but the board will send you a registered letter. At that point, depending on the severity of the issue, they will probably ask you to do remediation classes. If it was related to drug issues, you may hear sooner than that depending on the state you live in. At that point, you will be asked to join their program and follow very strict rules in order to save your license. It sounds like the employer was faced with something they hadn't really experienced before so who knows what they're doing. I hope it all works out for you. If nothing else, you are learning that when it comes to a nursing license, they don't play!

I have been a nurse since 1999. I started out in surgical nursing and went into oncology. I was then asked to be the night supervisor of a 46 bed med/surg/tele unit. I did that for 7 years. I am now a nurse manager of a 65 bed traumatic brain injury facility and I have just started to cross over into the Quality department. Ironically enough, I was just asking my friend last night how I should go about getting my JD so I can be an RN, BSN, JD. Pretty awesome, I think. Anyway, I have always enjoyed working with male nurses because there is little drama to deal with in the way of gossip. Although, some men can be just as high-maintenance as women! I also like working with male nurses in the acute setting because they were excellent in codes, patient lifting, and protecting others when it came to violent patients. Let me say that the wisest decision I ever made was to work on the busiest floor in the hospital (the one everyone hated) because I learned time-management and critical thinking that has followed me thru my career! I always told new nurses that if they could do 6 months on that floor, they could work anywhere in the world! I will be honest, I didn't become a nurse because I am interested in saving the world and I am far from a Florence Nightengale type. I became a nurse because I wanted to have skills and contribute, no matter how small, to the world. I have learned that you can't save everyone but even being there for the family at the end of someone's life is contributing. I also wanted job security and a decent living. I have an associate degree and I am about to graduate with my BSN in August. I have earned no less than $70,000 every year since 2002. I never intended to get rich in nursing but I live pretty comfortably. I always like the extra shifts because they pay so well. And let's face it, I wear scrubs and comfortable shoes every day! Nursing is the most difficult and most rewarding PROFESSION I can think of. It's a lot of work but the pay-off is awesome! I should also add that nursing is also pretty thankless. Every so often, you get the patient or family that couldn't imagine their care without you; others, will chew you up and spit you out. Never a dull moment! My wish for you is that you find your bliss, get all the skills you can, never say NO to an opportunity, and offer yourself up when you have down-time. All of those moments are learning opportunities that you just store away and before you know it, you are the one everyone comes to when they have a question or need help (or want you to start a difficult IV line!). In nursing, and again, there is never a dull moment. Good luck to you! Sincerely, Biggirl71

Congrats to you! I have faith that you passed because you are so sure you did! Back when I took the test in 1999, I had to wait 2 weeks for my results and it was excruciating! I too got 75 questions and I left there feeling sure I passed. I'll be honest though, as the days passed waiting for my official results, I talked myself out of passing about 100 times! LOL I checked the mail one day and there it was, my official nursing license. I was so proud that day. It was one of the biggest accomplishments I had ever achieved. Good luck to you and welcome to the nursing PROFESSION! Get ready for the most difficult and rewarding career I can think of. Sincerely, Biggirl71

I forgot to add that this Quality gig is new for me. I have spent my career in Management/Supervisory positions and I have dealt with nursing issues all along. However, working in the Quality department is a different animal all together. Out of this investigation, I yielded information on how to better design the nurse's notes. There is a section (basically a check-off) that addresses "edema." This section does not allow the nurse to indicate where the edema is but all of the nurses documented 4+. So I took my concern to the Director of Clinical Services and she is going to redesign the nurse's note. Another positive result of this investigation is that the DCS will do teaching to the nurses about the importance of accurately documenting I&O on renal patients (actually every patient) but especially real patients. Thank you all again! Have a great day! Biggirl71

OK, I am happy to report that the dialysis notes were located by medical records and I am so happy the nurse was meticulous in her documentation. The report from the day the pt. coded, the nurse documented that the physician gave an order to infuse the blood "wide open" to bring the blood pressure up from 50/30. I agree that this pt.'s condition was precarious prior to dialysis and the code could have happened regardless of dialysis. The second patient she took care of was NOT coded but sent out emergently related to SOB. All vital signs except the O2 sat (88%) were stable. The physician ordered a STAT CT to r/o PE and our facility could not complete that fast enough so the pt. was sent to a facility that could perform the CT STAT as ordered. The pt. did in fact have a PE and stayed in the hospital for 7 days to resolve the issue. The nurse did nothing wrong and as a matter of fact, followed all protocols and procedures. Thank you all for your time and attention to my questions/concerns. All of you got me thinking outside of my usual ways. These incidents just go to show that situations are not always as they first appear, I am happy to report! Thank you again and I will bring future concerns here as they arise. Sincerely, Biggirl71