Djadia

I work at a critical access hospital that has decided to standardize the process organization wide in regards to work flow in getting patients to med surg in a timely manner. Aliitle background....I work night shift that is short staffed - often only having 2 nurses to primary care 6-8 patients (occasionally we get lucky & have a tech.) Lately our patient load has consisted of high acuity patients although our CNO staffs based on the "number of patient's " he feels we can take. My concern is if both nurses are in a room transferring a patient via hoyer / ezstand - that leaves noone to be available to get report or answer any phones at that time. We obviously don't purposefully not answer calls. This doesnt allow us to have the conversation re: our ability to 1) safely care for the patient. 2) room assignment based on isolation status, patients confusion etc. The ER will now make the room assignment & if no answers in 10 minutes - they will drop the patient off & the RN can call for report later. Our facility has an ER & med/surg floor only. We don't have other floors to pull staff from if we need help. Its only us! How is this going to affect patient satisfaction - when they are dumped off & having to sit in a room till staff can see them. Obviously our care is prioritized based on patient need (given our minimal staff) & there are times that a new admission would not be priority. I'm looking for feedback/opinions regarding what others think & if this is the correct way of handling our admission process.

I have suggested this to our Nurse manager (who also has been a nurse on our unit for 3 years) because when I initially started working at our facility 30 years ago - our pulse oximetry was connected to our telemetry units & monitored at a central station. I was told that we need to make do with what we have available - that is why I turned to this forum for advice.

These patients are in rooms a great distance from the nurses station especially those in isolation. It's difficult hearing the alarm even standing right outside the door & impossible to hear from the nurses station. I completely understand the liability of silencing the alarm & agree with you 101% however, from a patients standpoint (especially those that are confused & have dementia which are the primary population of patients we care for) having the alarms go off without anyone hearing them over stimulates their environment causing them to get out of bed and be at high risk for falls. I feel that there should be a centralized way of monitoring these patients at the station. . We currently monitor telemetry at the nurses station - is there a way to connect the pulse ox cable to the telemetry box. I now that approx. 20 years ago we had that capability however I have been told that this option is nolonger available. I find it hard to believe especially with all the advances in technology & wifi transmission. In my opinion, it would be the most cost effective way to assure our patients are being monitored without the added expense. My issue is convincing management that this is a necessity. I have been researching case law to find cases where a hospital was liable for neglect in adequately monitoring a patients respiratory status. I feel that legal liability /risk management would be the only convincing perspective. What are your thoughts?

I'm looking for input from the forum in preparation for a department meeting next week. I'm a nurse on a med/surg unit of a critical access hospital that sees alot of patients with respiratory related diagnoses. (especially with covid, influenza & now the norovirus - all of which require patients to be on isolation.) The Dr's order continuous pulse oximetry. We have been using portable vitals machines to monitor pulse oximetry on these patients. Granted, the alarms are set but when in an isolation room with the door closed its difficult to hear the alarms. Patients complain that the alarms are constantly going off making it difficult to rest. I addressed this with our nurse manager who responded with "face the vitals machine towards the door & check the patient every 1/2 hr." Alot can happen in a 1/2 hr (like a patient dying) and I feel we are setting ourselves up for a legal liability especially since we are not following what the Dr. ordered & we are unable to assess if our patients physical status is rapidly deteriorating - Delaying treatment interventions in a timely manner. What do other facilities use for monitoring patients on continuous oximetery? Would the nurses be negligent if something happened to a patient that was only checked on every 1/2 hr? Does our current way make us non compliant with standards of practice? I want to be prepared when presenting my concern at the meeting. Any "legal" advice would also be appreciated to support my concern. Thanks in advance for your advice.

Can I legally refuse an admission d/t patient safety without receiving a corrective action? Last evening we had exactly that situation. We called the DON when ER called with an admission- a 21 yo. with severe hypocalcemia/ tetany. This was not an appropriate admission given the risks of cardiac arrest, seizures etc. We already had 12 patients - including 3 tube feedings w/ q4h flushes, 4 patients that required 2 person transfers/repos. 1 covid pt & 2 fresh surgicals. The DON asked if we felt safe taking the admission. We obviously said no. He said he'd call us back. When he did his response "I told ER to send the patient to the floor" - no questions asked! I don't want to jeopardize my license - but it's not safe. Can I refuse to take an admission without retaliation from management or getting fired?.

I work on a med surg unit in a rural critical access hospital. Our 20 bed inpatient unit & ED are the only units staffed 24/7. Our ideal staffing matrix is 2 RN's & a tech on each shift. We currently have a 1 full time RN position & 1 full time PM Tech position open. Our current staffing ihas been 1 RN & 1 tech . We don't have specialty services available ie; IV starts, wound care, RT, foley catheter, or pharmacists on site. We had a staff meeting a few days ago & our new DON presented us with a letter "effective immediately, the Med-Surg unit is nolonger allowed to deny patient admissions from the ED, Swingbed Program or transfers from other hospitals. It is essential that we maintain a seamless and efficient process for patients to ensure quality care & timely treatment. Under no circumstances should a patient admission denied without following this escalation process. Failure to to adhere to this workflow will result in immediate corrective action" Staff feel as if patient safety is extremely compromised & We don't have other units to call & ask for help - it's all us. Most of our patients are 2 assist transfers which leave noone else to answer call lights, hear bed alarms especially when both staff are in covid rooms. Not to mention , I nurse must round with our new teledoc services which has been averaging 1 hr per patient- leaving 1 tech to cover all the others patients. Our decision to admit patients is nolonger based on acuity, 1:1 observation, cardizem/ insulin / heparin drip, confused patients etc. Our DON sees no problem with 1 nurse to have 8 patients. 75% of our staff has applied for new jobs elsewhere, have interviews,or cut down to casual status. I'm in desperate need of advice - is the DON legally able to enforce this process even if it's not safe? What are our rights as nurses? Is there anything I can do to save our unit?

We have recently on boarded telehealth docs as our only providers in our critical access hospital. I'm looking for advice as to the legality of patients being made aware that "teledocs" will be following them BEFORE they are admitted? We recently had patients who were NOT informed & were very angry because they would have transferred to another facility. Our DON said that "there is no law stating that patients need to be made aware of them only being seen by teledocs" . I DISAGREE. What are your thoughts?

We have a great team of nurses. The majority of our staff has already applied for other jobs pending the decision to go forward with the "tele doc" process. We are having a staff meeting with management who sent out an email "bring your list of questions so your voice can be heard". I'd like to be knowledgeable & prepared by knowing what is legally within our scope of practice. I agree, complaining isn't going to change a decision that has already been made however if I can state 'facts" of what we can, as nurses, legally perform would be beneficial. Without staff - a process can't be initiated.

I really appreciate your response. I've been a nurse on this unit for 30 years & have seen how healthcare has revolved. Our patients use to be the "center" of healthcare however it has become a "how can we make more money by getting away with less". The expectations of our older population is a doctor physically assessing them inorder to arrive at a diagnosis. When they (& the general population) become aware of a "tele doc" being their primary care physician while hospitalized- I forsee them going to a larger city hospital thus resulting in the rural hospitals to close. At the end of the day, I worked too hard to get my licenses' - to lose them to a poor management decision. Again, thanks for your insight & advice.

We are a rural critical access hospital with a 20 bed acute care med surg unit that are under new management. Our primary care doctors round during the week on all acute care patients. After hours & on weekends our ER MD serves as hospitalist for all patients. In 1 week, our primary docs will stop rounding on hospital patients. The company that staffs the ER physicians nolonger will allow them to round on patients on weekends. They will give night shift orders " to get by" only. Our management has arranged for "tele docs" to round with nurses on weekends ( which will also soon be every day) They complete H&P's, order meds/procedures, & inform nurses of new orders that WE need to enter. Our staff doesn't feel comfortable with doctors who never saw the patient ( other than via TV screen) - base a patients plan of care/ orders solely on a NURSES ASSESSMENTS. We are short staffed & don't have the time to care for our patients & spend time rounding & putting in orders. I'm concerned about this process from a legal standpoint. Any advice would be helpful.

Thank you so much for your response. It is reassuring that there is light at the end of the tunnel.

I have been an RN (associate degree) for 26 years on an inpatient medical/surgical unit @ a rural hospital which has given me the opportunity to perform various tasks that large hospital nurses may not experience. We perform chart & pain audits, complete patient med rec's on admission, care for hospice /outpatient patients, assist in the ED, perform EKG's & monitor patient telemetry. I love nursing but no longer feel challenged. I would rather transition into a work from home career reviewing medical records, claims review etc. I've noticed that the majority of case management jobs require a bachelor's degree & DRG coding /medical billing experience which I do not have. I'd appreciate advice on how to begin my job in case management. Should I enroll in a DRG coding & medical billing program? Does my years of experience as an RN pose an advantage for me? Any advice would be appreciated.

We are a rural hospital & the only RN's in the building during NOC shift are 2 on med/surg & 1 in ED

I wasn't the person who followed the managers reccomendation to chemically sedate the patient because I'm having no part in "illegal" nursing. I merely was a patient advocate. How can i be labeled as verbally abusive for being concerned for patient safety & NOT admitting the 11th patient when we cant adequately care for 10 & for not putting my license on the line for being well aware of the situation before it occurred?

"Verbal abuse" is quite a severe accusation to have on my permanent record. Other staff in attendance at the meeting were shocked to hear the result as well. Am I able to enter a comment in my personal record as to why I do not feel this is a fair judgement on her part?