FarrellGirl,RN

Thank you for the responses. I AM currently looking into other employment (besides the fact that I feel like my license is in jeopardy every day I spend there, I also want to get out of LTC--I am open to LOTS of possibilities). I have also made up my mind to REFUSE to endanger a patient by "following orders", and put my own career and future on the line for her absurd rules. I really would prefer she fire me. I'll just get unemployment until I have my next job since I WILL have grounds for wrongful termination. So I will have plenty of free time to find a GOOD position. I must admit that I felt TERRIBLE about following her orders! I felt extreme guilt. The patient later needed clysis because we couldn't access her fragile veins and she became dehydrated. In the hospital, she could have had a PICC placed. Actually, the night that happened, the DON asked me what her code status was and when I said, "DNR-CC", she said we should think about getting a HOSPICE CONSULT! The patient is NOT terminal. She had two acute illnesses (the UTI and later, after the CXR, we found out she had some small infiltrates). There's a male patient I take care of too, and he had a stroke and has not been able to eat or drink due to dysphagia, she ordered MARINOL, and the man is already miserable because he's hungry and CAN'T eat, and she just ordered something that would make him MORE hungry. The doc ordered an EGD and the hospital refused to do it because he couldn't swallow something for the test. They won't okay a G-tube without EGD results. So the "answer"? hospice. To me, speaking as someone who has seen him 40 hours a week for a long time and knowing his condition and family's/POA's wishes, it's inappropriate. The aspect that really bothers me is that I have been working that unit for a year and a half. I KNOW these patients! This woman hasn't even SPOKEN to most of them, she hasn't been there long enough. AND, she wasn't there! I was there! I know this patient (the female patient with the UTI)! I have known her the entire time I have worked at this facility, and I have performed enough head-to-toe assessments on her that I almost immediately know when something is wrong. I feel like the DON is the nurse equivalent of Dr Kavorkian! Her answer to everything is hospice. As a caring nurse (one who cares not only about the patient, but their families as well), I feel like I am doing wrong by them, and I guess that is why I have stayed so long. I felt like I needed to protect them.

I work at a LTC facility in Ohio on the night shift, and I recently have had several run-ins with the DON about her new rules. I've been working there for over a year and a half, and had never been corrected before about my charting or my nursing decisions, but now this new DON is enacting some new policies I feel are not only neglegent, but also over-step her authority. I am looking for some insight before I inform her that I need to have a sit down discussion about her rules and the way I feel I am being treated. The first incident happened the weekend before last, when a nurse who was supposed to have charge of a floor with 38 patients, called and QUIT 25 minutes into her shift. I called the DON (she was "on call") to ask what her plan was. She said I would need to take another set of keys and another floor as well as the floor I was already assigned to. She said she COULDN'T come in because she was 600 miles away in another state. Again, the next night, I had to do the SAME thing because she was still there and NO ONE was found for the other unit in 24 hours when she was already aware of the fact that the nurse was scheduled for Sat and Sun. On Mon morning she pulled me into her office, claimed that a patient heard me say, "don't come to me unless you're dead or dying" (something I would NEVER say), and that she SHOULD write me up, but that she didn't want to get off on an adversarial footing with me. I told her I would NEVER say anything like that, and I refuted the claim. She accepted that, but said that there may be times I have to take two units (I THOUGHT there was a ratio that was illegal and that I did NOT have to accept the responsibility of another unit I was not assigned to. It is also common practice that a unit manager be called in at those times. At least that was how it used to be BEFORE she became DON). The second incident REALLY angered me on many levels, but I felt as if I were being bullied and could not do anything about it. She enacted this new rule that all nurses had to notify HER before calling the physician to have a patient sent out to the hospital. I had an elderly female patient who I already knew was positive for UTI, who had a DRAMATIC change in physical and mental status (she can usually ambulate to the toilet, but lacked the strength to take one step; she can usually speak intellgibly and with appropriate content, but I could not understand anything she tried to communicate). I called the DON, as she requested, and she said, "No. We don't send people out to the hospital for acting funny." and suggested I get lab work that would take days to get back, and even said, "I wouldn't call TONIGHT, though". So I called for the labwork and CXR anyway, and charted that I had notified her (including her name), wrote the incident report because the patient was lowered to the floor due to weakness, and reported to the dayshift nurse about her condition. The day shift nurse ALSO thought she needed to be sent out, but was also intimidated by the DON. The next day I worked, the DON stated, "Don't chart my name in the chart. You can chart 'oncall RN', or 'DON', but we don't use other people's names in our charting". So my questions are: CAN I refuse to take on another unit if I don't feel I can safely manage them all? I know I can ignore her and call the physician and have a patient sent out anyway, but can she legally reprimand me for that? Can she really even tell me NOT to send her out? Can she make herself physically unavailable in the event that she is needed in the facility when she is oncall? I feel like she is taking liberties with my license that I do not accept. I KNOW she doesn't want anyone sent out because she wants to keep the census up. And I definitely know she made up that stuff about a patient overhearing me say not to bother me to try to intimidate me into doing whatever she says, and that her patronizing tones and speech are a form of verbal/emotional abuse. But what are my options? Am I just going to make an already hostile situation worse?

I always adhere to the hour. But I work on a secure dementia unit. If they're asking for it (which few of my residents ASK for meds), I'll get an order to increase the dose. What irks me is when someone writes an order for something "BID PRN". TID is no big deal. I can see a Q8. Or QID...I can understand a Q6. But BID PRN for a med like xanax or percocet for a resident that is ALMOST always anxious around the same time of day (I work with a lot of sundowners) and could use an anxiolytic twice a day, but within about 6 hours? It needs to be written, "Q6 with a maximum 2 doses per day". But, as I said, I work a specialty OF a specialty in my facility since they're all advanced age and dementia, usually with psychosis or behavior disturbance. Though a lot of nurses I work with don't understand that their agitation is sometimes a result of pain. I love knowing there are other nurses out there who really care. The place I work at makes me think we are few in number (those who actually do the job and care enough to assess and make them call to get the increase order). Though I will say, there is one scenario where I do fudge things and that is with a patient who is actively dying. I don't like waiting to relieve their pain and anxiety.

When I started, I was passing 9am meds for 38 residents because I was the only one WORKING on my unit while the other 3 nurses stood around doing nothing and calling it "supervising", arguing about who had what administrative position. It was pure hell. But I did pick up a few tricks that are legal and cause no errors. 1. Pre-pour waters: set up like 4 or 6 cups of water at a time so you're not constantly pouring and you don't forget to pour water. Just don't forget to pitch the cups after they drink from them. 2. Do those with PT first and premedicate if appropriate (say on someone with an amputation who's going to be working with a prosthesis). That way you're not faced with a lot of PRNs at once, and keep it in your mind who's likely to ask for their PRNs as soon as they can have them (ie "clock watchers"). 3. Figure out who's a fingerstick and highlight your census so everyday you know exactly who to get and when (I used to use orange for only 8am, blue for 11am, and green for 8am and 11am). 4. Do all your blood pressures/pulses/temps first so you know gets b/p meds and ABTs and you'll be able to assess who you may need to monitor closely for falls and possible calls to the physician that way you can prevent incidents from interrupting your pass. 5. Make sure you have EVERYTHING you'll need on the cart. You'd be surprised how much time it eats up to run get supplements, OTCs, thickener, thermometers and other equipment. 6. EAT BREAKFAST!! Seriously. When I first started on the floor, I never ate breakfast and by 8:30 I was sluggish and moving and thinking slower. Also, don't gauge how fast you are by how fast other nurses get it done. It has been my experience in my year of nursing that those who get the most praise for being efficient aren't really giving all their meds. I have come behind nurses who signed that they gave eye drops from unopened bottles, meds that were unavailable, signed for uncommon meds for days and not a single pill was popped out of the packs. I've seen nurses write in O2 Sats when there wasn't an oxymeter in the building, so I don't doubt some of them make up vitals and write them in. I try to practice nursing as if it were my loved one or myself I am caring for. I would rather give them all their scheduled meds late, but safely without lying or making errors than for them to not get some or any or receive them in an unsafe manner (like getting B/P meds when their B/P is too low). It really does get faster with experience. Just try to avoid bad habits like prepouring. I won't lie and say I've never done imperfect things and we're all human. But I have made errors before doing those types of things, including wrong med to wrong patient. Personally, whether harm results or not, I always regret those kinds of things and feel terrible when I make a mistake like that. You'll get it. Just stay at it. :)

Other nurses drive me nuts with the narcs. One likes to reorder WAAAY early and our pharmacy is so backwards, they send out refills of stuff 40 pills in advance when it's unnecessary and then put a refill sticker that you have to pull on exactly that day or someone won't get a scheduled narc (and I HATE signing and circling). Then you got those nurses who LOOK for pinholes and waste narcs if the foil on the back is even scarred (not to mention almost everyone keeps rubber banding packs too tight so they're almost ALL buggered up). So then the count goes something like, "Jane Smith: Ativan, 28 with 20, 16, 9, and 2 out"...and there's a repeat offender who constantly does that. I think she does it just to make me crazy. Then the other day, this one steel-faced nurse relieves me after my third 12 hour shift in a row and I said the wrong number. Now, don't get me wrong, I don't mind at all if they want to visually see the narc book during count. But this wretched person grabs the book, hovers it, and wants me to look over her shoulder and call out the numbers treating me like I took the pills. I was like, "Do you really need me for this count, or do you want to do it yourself?" If she hadn't had her TWO very YOUNG children at work with her (which is just unprofessional to me, and I say that as the mother of a 6-year-old), I would have said something more like, "Count 'em yourself b__ch. They're all there, and the ones I signed out were routine". I wouldn't mind boxes if I worked with a different set of people. Though I give the first shift nurse I usually relieve and get relieved by credit because we never have issues...caused by anything we've done. lol

I had the same problem for over a year. I graduated September of 2009 and got my first job in November of 2010. I do NOT have my dream job. But after putting in over a thousand applications from Med/Surg to school nurse, I had to have a job. I bit the bullet. I payed over $40K for my education, I'm a mom, no one else pays my bills, and I had to make a living. You know what sector of nursing is easiest to break into? Long term care. It's not glamorous. I haven't had to do a code in the 9 months I've been working there. In fact, most of my patients (which are called "residents" in my sector), are DNR and if they're full code and start to decline, 9 times out of 10, they change their code status to DNR. But I've only been there 9 months and I have 2 weeks of PAYED vacation built up already. I go to work, make my money, and leave. I'm on a secure unit for residents with dementia. I feel more like a daycare worker than a nurse. However, my employer offered my $5 more an hour to start than the hospitals were offering, I got my choice of where I wanted to work. I'm paying off my loans. And my job is so low stress, I can easily go back to school. Just an option for you. It can be a career too. Nurses work their way up to becoming DON's (consultants) and making twice as much as a new grad. I make more than the average RN in my area, and I'm a unit manager already and as I mentioned, I have only been a working nurse for 9 months. Good luck on whatever you decide to do.

I am licensed by endorsement in Ohio. My license expires on August 31st. I just moved from Kentucky to Ohio and have not yet done my change of address. Did I miss something? Do I have to redo that whole packet? I read where some people got a renewal letter. Was it by certified mail or something and I had to sign for it but I missed it cause it went to my old address? HELP!