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 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?

Ive been employeed @ the the same acute care facility for 24 years. The manager I recently submitted an incident report for her recent recccomendation to chemically sedate a patient d/t lack of staff available to do 1:1. In addition, at out facility the night shift has only 2 nurses & no techs. The only additional help we have is from lab & radiology (if they aren't busy). Lately the acuity of our patients have been high. 5 of 10 patients require minimum of 2 people to transfer which leaves the other 9 unsupervised while we are those patients rooms. Our manager sees no reason why we cant take additional admissions through the night. At the last unit meeting, I told her i was concerned about the patients safety seeing as though we had 2 falls in last 3 weeks. I also told her that on those nights of 10 high acuity patients with only 2 RN's, I will inform ER that we cant accept admissions as to not risk patient safety or jeopardize my license. She wrote me up for being verbally abusive. Do I have any rights in these situations?

Your response couldn't have came at better time. It's reassuring to know that someone understands & can offer advice. I've accepted the fact that if the dynamics on our unit don't improve, I need to move on. I can't be a nurse in a facility that nolonger shares the morals & values of why I chose nursing as a career. Thanks.

I have been a nurse for 20 years & have had many managers, but the current manager of our med/surg unit is destroying our unit. I work @ a 24 bed rural hospital in a small community where we know a majority of our patients on a first name basis. Our current manager of 2 years has ruined staff morale, our staff turnover is the highest it has ever been. We are short 2 full time RN'S & 2 Tech positions. She has told several staff " if you don't like it here then you need to look elsewhere for a job". Our staff is dedicated & provide excellent care to our patients. She has recently told an RN "you have 30 secs to talk to me, after that I'm not listening". She doesn't believe in having to compliment staff for doing the job they were hired to do. Communication is non existent unless there is something that was done wrong. She doesn't return phone calls, answer emails or communicate pertinent information that is needed for the dept to run smoothly. I see how she is ruining our department which has affected the care we provide to our patients. Given the fact that we ARE a rural hospital - every patients bad experience infiltrates the community & changes the outstanding reputation we are known for as evidenced by lower patient scores. I am in desperate need of advice regarding what to do. I can't sit back & watch our valuable staff quit & non existent morale continue. Upper management has seen our rapid turnover, open positions & decrease in patient scores but yet hasn't intervened seeing as though the staffing issue has been going on for at least the past 8 months. Staff is being mandated for the open shifts & are Simply Burned out & calling in sick. Any advice is desperately needed.

I recently encountered a patient fall partially r/t hospital door not alarmed. Patient was an 86 y.o. female who's POA was activated & experiencing D.T's from ETOH withdrawal. Pt attempted to get out of bed every 10-15 min. even after receiving Librium and ,Lorazepam as per hospital protocol. The Tech forgot to turn on her bed alarm before leaving her room. 10 minutes later patient walked down hall,passed thru 2 hospital doors (which weren't armed). Pt was found by the tech,who heard the patient yell outside the door lying on the ground. Patient had only a laceration on elbow. When I called maintenance as to why the alarm wasn't on the door, he said it depends if the alarm toggle switch was in the ON position. When I looked @ the panel & said no lights were on- either yellow or red - his response was " Not all the lights work anyway. You'll have to open the door to see if its alarmed. Had the door been alarmed, the patient wouldn't had fallen or gotten outside. Manager said it was nursings fault & not maintenance. What are your opinions?

I work @ a rural community hospital approx 15-20 beds. We recently implemented Bedside report on our med/surg unit & have encountered a few obstacles along the way & am hoping that someone could give me a few suggestions. 1). We have several same-day surgery patients that stay overnight & discharge in the AM. By the time the patients finally receive pain relief & just fall asleep - Night shift come in & we do bedside report. Patients get angry when we wake them up but I also understand that a fresh surgical requires close monitoring ie: dressing, IV's etc. When we do bedside report, it's not until 1/2 later that the oncoming shift then does their assessment & vitals. How are other hospitals handling night shift report. 2). In regards to staffing, we attempt to pair up the RN's with the same TC/CNA's so bedside report can be done together; however this is not always possible. In addition, my shift starts @ 3pm and one of our TC's come in from 4p-12 to assist in the "overlapping" of pm & night shift. We then need to give her report & not to mention, the beginning of the shift is the busiest & we don't always have time to stop to give report. I'd be interested in hearing how other's handle this issue. The may seem minor - but it only take few coworkers to make it a major issue.

Given the increased infection rates and reimbursement based on new aquired infections while a patient is in a hospital, how can I just overlook this surgeons practice. If this patient would develop a new infection, I'd have a difficult time knowing what I know & not pursuing the issue. Reimbursement is a hospitals vitality.Medicare won't reimburse for infections aquired while a patient is in a hospital If this surgeon follows this same practice on other patients - Its the patient & nursing staff's burden not the surgeon. As nurses, we could be facing the repercussions not the surgeon. When does this vicious circle end?

We currently have a paraplegic on our unit with 2 extensive wounds on his left leg which are currently being managed with a wound vac. During one of the vac changes a few days the surgeon was present during the wound vac change and "took over" the wound care. He encountered difficulty in removing the foam dressing that was packed in the tunneling part of the wound. He picked up a scissors from the patients bedside table (which defineately was not sterile. It was used for cutting tape etc. not to mention - it probably had fallen on the floor several times etc.) and proceeded to make 3 large cuts within the wound to allow him access to the tunneling dressings. Granted this patient had decreased sensation in that leg but could feel pain the deeper one probbed. The surgeon didn't tell the patient what he was intending to do, nor did he ask the nurse to get him a sterile scissors. The issue I have is that I was not the nurse present who witnessed this surgeons actions. The nurse who was - refuses to report the surgeon seeing as though she works with him frequently. In my opinion this is ethically wrong, and it appalls me to think that this surgeon would have done this. It defineately makes me wonder what other things he may do that noone witnesses. Do I have an obligation to report this to our nurse manager or do I stay away from the entire situation seeing as though I wasn't directly involved. I already talked with the nurse who was involved and encouraged her to report the incident however, she declines to do anything further.

Thanks for the reply. Sometimes it's nice to get someone elses opinion.

There recently was a patient on our Med/Surg unit who had a dual lumen Power PICC placed during surgery for TPN & Lipids Infusion. 48 hrs later, his arm was edematous, red & warm. An ultrasound was done on his right arm which yielded the presence of a clot in the Basilic, axillary, & subclavian vein. The anesthesiologist (who inserted the PICC) was notified. He stated that we could continue to use the PICC seeing as though the clot wasn't in the PICC Line. Was his statement correct. Is it recommended to use line especially if it is being used for an infusion of TPN/Lipids?