LPN01112005

My employer has stated they will not pay over-time, but all that meant was that we were not to work a minute over. I refuse to work off the clock, and I have been paid time and a half for the few minutes I've had to work over in order to get the job done. In a perfect world, we could just give report and leave on time every single day, but this is health care and sometimes stuff happens that causes us to have to work over. Admin. knows it, and better, they know I know it. So as far as I'm concerned, I work diligently in an attempt to be off the clock on time, but if something causes me to have to stay a few minutes over, then I stay and finish my documentation, etc. THAT I am required to do to keep my license unencumbered.

Gives PRN narcotics to residents who rarely/never c/o pain when other nurses are assigned to them Gives PRN's at every opportunity....say q4hr to residents that NEVER have to have them that often when others are caring for them Let's it be known to other staff that she has a "script" for Lortab, Ativan, Xanax, etc...... and that she "had to take some" before coming to work. Has residents c/o that they didn't get their scheduled dose of pain med at xx time, however, diverting nurse will say "they are just confused" and her documentation will back up their c/o pain, her administration of pain meds, and of course, some form of confusion on the residents part. Comes to work wide awake, but as the shift progresses, becomes more and more somber. Signs her narcotics out at one time, instead of the correct way....when she gives them. Leaves the facility for a "break" immediately after her med passes Goes to her car for mini breaks throughout the shift. Fentanyl patches on her residents are frequently found to be missing after her shift, however most often she is clever and will document that it was not found during her assessment on her previous shift. There is no rhyme or reason to the way she works, in other words, she doesn't have a system. She is all over the place, in and out of the med carts, backtracking to "skipped" rooms. She offers to "check in" pharmacy deliveries for other nurses. She has to "refer" to her narcotic book during charting. ***? You are giving so many narcs that you can't remember who you gave them to? PU-LEEEZE

Try to calm down. If you didn't take the meds, then you'll breeze through the investigation. Like a previous poster said, just because the pharmacy notified you, doesn't mean you are the suspect. They just have to notify and you happened to be the person on duty when notification was made. My suspicion is that someone diverted the drugs and the card. Believe it or not, at both LTC's that I've worked at, this type of diversion has happened...more than once. Most often, it was a night shift nurse who had diverted the blister pack of pills and the sign out sheet that they thought no one would miss. LTC night shift is the perfect arena for impaired nurses to divert. Right now, I'm working with one that I (along with several other nurses) suspect is diverting. Can't prove it, but the tell-tale signs are there and it will be a matter of time before she slips up and gets caught. DON and Adm. have been made aware, but they choose to ignore "suspicions". Ok, well whatever, but you mark my word....it's happening and she'll get caught. I just hope no harm comes to her residents in the meantime.

Although the first person to address the wounds should have been the admitting nurse, the fact that she or he didn't do it, does not let any subsequent nurse off the hook. I am the Wound Care Coordinator for a LTC facility. I would have written up every nurse who had been assigned that resident from the time of admission to the time all wounds had been documented and appropriately treated. A head to toe skin assessment is to be done upon admission with photo documentation of any wounds present on admission. The appropriate tx orders are to be obtained, and the treatment record completed. This has to be done within 24 hours of admission. To not do so is simply negligent. What one shift couldn't complete should have been completed by the next shift. Wounds are a big deal. They progress very quickly when left untreated, especially in ill residents. What is a small area of discoloration on Friday evening could be a Stage III or more on Monday. To wait on the treatment nurse is nothing more than laziness on the part of the nurse doing the "waiting". I am simply appalled that your facility doesn't enforce a 24 hour rule on admission and readmission skin assessments. Just a tag waiting to happen if you ask me. Let this be your tough lesson. Take your write up, and learn from it. You are there to serve the resident, and sometimes that will include picking up the slack of the nurse you relieve.

Actually, signing the MAR and TAR after the med pass and treatments IS the problem. If the nurses would sign the MAR and TAR as the give the meds and do the tx. then holes wouldn't even be an issue. At our facility, believe it or not, there are a few nurses who never have holes and they are the ones who sign as the give.

At our facility, the med order goes on the MAR at the time the order is noted. Meds are taken from the Emergency drug box on each unit for the doses that will be due before the nightly pharmacy delivery. If the order is for a med not readily available in the Emergency drug box then either there has to be an emergency delivery by the pharmacy or one of the Unit managers has to go to a local pharmacy to pick up the doses that will be due before our facility pharmacy delivers. This requires communication between our local pharmacy and the facility pharmacy, however and we avoid having to do this. Sometimes, the MD or NP will give the order for the med to start when delivered from the pharmacy. We are not ever allowed to write med unavailable on the MAR, and we most certainly cannot just leave holes! Nor or we able to show a lag time between the time the order is noted and the time it goes on the MAR. That's a tag for sure for not following MD orders. We try to get all MD orders in to the pharmacy before 3:00 p.m. to ensure that the meds will be delivered that day, however sometimes that isn't possible especially in the case of new admits and readmits, so these are called in to the pharmacy as soon as the orders are verified and they will usually be delivered with that night's delivery. Every nurse in the facility has a list of drugs available in the Emergency drug boxes and Emergency narcotic boxes and if the order is for a drug unavailable it is the noting nurses responsibility to alert the MD that we do not have this med on hand and get further instruction. I'm not saying this always happens, but this is facility protocol. Sometimes, nurses are just lazy and they "borrow" a med from another resident, which everybody knows is a big no no. But yet still it happens a lot. Then, when the pharmacy consultant catches that "now" orders were not taken from the e-box, the offending nurse gets all defensive when HER error is brought to her attention. It never ceases to amaze me, the indignance you see in some people who are being held accountable for imporoperly doing their jobs. Medication errors of this sort are a topic of discussion at EVERY nurses meeting we have. I, for one, get tired of having to listen to the same gripe at every meeting we have and wish that all nurses would just note orders and carry them out properly, ALL the time. This is one of the easier "problems" that we as LTC nurses face. I just don't understand why it is one of the hardest to get the nurses to correct.

There are opportunities for RN's in LTC other than being the medication nurse. So, once you've gotten the hang of LTC, you could move into another position such as ADON, Unit Manager or MDS Coordinator or Wound Coordinator. I went to LTC fresh out of school, then went to the hospital med surg unit. Ultimately, I returned to LTC primarily because I missed the meaningful relationships that can be developed with the residents in LTC. Although, I did enjoy the hospital and I did get the opportunity to perfect skills, gain IV certification, Learn basic cardiac dysrhythmia interpretation, and advance cardiac life support. All of those were opportunites that had not been available to me in LTC. So, my hospital experience was very valuable and made me a more valuable and skilled to my employers. I am now the Wound Care Coordinator at my facility. A position that was previously held by an RN. I supervise one LPN and two CNA tx aids. When I was the Unit Charge Nurse I supervised 6 CNA's. One of our Unit managers is an RN, the other an LPN. We also have an RN RAI Manager and an LPN MDS coordinator. Our DON is of course an RN. The evening supervisor is an RN, as is the weekend supervisor. I report directly to the DON. The Unit Managers report directly to the DON, however, the LPN medicaton nurses and Charge Nurses report to the Unit Manager. There is some opportunity for an RN medication nurse to report to an LPN Unit manager. Seems like the lines could get skewed a bit. However, at my facility, there really doesn't seem to be any hierarchy in the RN vs. LPN department like you see in some hospitals. I, personally am made to feel like a lateral collegue to the other administrative nurses, whether they be LPN or RN, and honestly, I treat the LPN tx nurse and the LPN charge and medication nurses and the CNA's for the most part the same as I'm treated....like a collegue. We all have important tasks to do. Mine happens to involve a lot of paper work and not as much hands on direct care, but we are all a part of the same team. I know that technically any RN in the facility has the ability to be called the manager on duty or whatever and be the "responsible" nurse in the facility, because in every state, LPN's work under the supervision of an RN. But, on a day to day basis, the RN's don't run around "supervising" the LPN's, just because they can. I mean, the RAI Coordinator, with whom I work closely for documentation purposes, doesn't consider herself my superior. I work with her daily, and I don't think she's ever reminded me that she is the RN. I hope I haven't confused you, or made you feel like I think that RN's should in some instances be "under" the LPN because that was not my intent. I meant to convey that in some LTC settings, there isn't that much emphasis put on what your credentials are as long as your are capable of doing your job. LTC is stressful, staffing is ALWAYS at issue. I recently had to work the floor as a CNA due to call outs. I'm telling you, THAT is the toughest job in the world. I honestly could not handle it. LOL. But, it is also very, very rewarding. So much more rewarding than the hospital was for me.

Ok, I did it. I worked as a CNA last evening/night with a resident load of 17 due to another unexpected CNA call out. I was also the supervisor on duty. I was able to get everyone changed, toileted and put to bed without any injuries to myself or the residents. I was NOT able to adhere to the turn schedule, and the residents did not get changed q2h. Nor was I able to spend enough time with the residents who required feeding to get them to eat more than a bite or two. The LPN was busy passing her medication and dealing with the behaviors. She simply didn't have time to assist me so we could have "fun" making sure the residents were properly cared for. Add to this the fact that I was still the supervisor on duty and had all those fires to put out too. Most notably, trying to find staff to cover the call outs for the overnight shift, however I was unsuccessful, so I had to stay until 4 a.m. As soon as I got home and got to sleep, I get a call....someone has called out for 7AM, they were already short, I need to come back in. This time to cover for a nurse who called out. Are you kidding me? Can one on call person be expected to cover for the entire facility?

To be clear, I have worked in the hospital med surg unit. We were "total care", there were no CNA's, so the nurses did work as a team to provide all the care necessary to care for the patients. However, what I'm referring to here is a LTC setting where there are two LPN's and 5 CNA's assigned to 66 residents, 90% if whom are totally dependent with ADL's. The LPN's pass meds and assess the residents. The CNA's do all the ADL's, turning, toileting, incontinent care, feeding. So, although I have the skills necessary to "know how" to do the job, that doesn't necessarily mean that I can be effective or safe in a job I've never done before. To be clear, this is not about me not wanting to change incontinent briefs. I help out with that on a near daily basis even though I am in an administrative position. My concern comes with the transferring, bathing, etc. of immobile residents. I don't feel comfortable being thrown into a situation that has the potential to be harmful to me and to the resident. Ultimately, I am responsible for any assignment I accept, so I'm probably not going to be accepting this "assignment" out of fear that I'll jeopardize the resident and in turn, my license. Another thing, what about being forced into a subordinate position to those nurses that I supervise on a daily basis? Exactly who is the supervisior? Are they without one? How do I take on the role of nursing assistant to a nurse that I am actually supervisor to?

Can an on-call nurse be forced to work as a CNA? My administrator is demanding that the on-call staff (I am part of the on call rotation) fill in as CNA's. This is not about me thinking I'm better than the CNA's, but the fact is, I'm not a CNA and have never worked as a CNA. I don't believe I can physically do the work at least not without a proper orientation period, which isn't being offered. In addition, when I was in nursing school we were discouraged from ever working in an unlicensed capacity once we were licensed. Has anyone else had to deal with this, and if so, how did you handle it?

Natural nails only and they must be trimmed. This is an infection control issue. Polish is ok as long as it isn't chipped.

I just took a job on a "Busy but Doable" Unit. HA HA HA. It is only doable if you skip meds that some nurses consider too time consuming like med pass, eye gtts, nasal spray, colace, propass and neb tx. I was actually oriented to my unit by an agency nurse and I saw first hand that this is what she did in order to get out of there within an hour of shift end. Forget any of the "extra" stuff like reordering meds, etc. While my administrators say they understand my frustration all they can say is that they are working on making the job easier. Well, until the DON takes over that med pass for a day or so alone she will not "understand" how UNDOABLE it really is. I REFUSE to skip medication, I REFUSE to be rude to the residents or their families in order to be able to get out of there within 30 minutes of my shifts end. They will continue to pay me overtime if they intend to keep me without easing the load on that Unit. There is no ward clerk to answer the phone, make appointments, and schedule labs. Currently there is only one RN Charge in the entire facility so, needless to say, help with admissions, readmissions and incidents isn't even an option. I honestly don't know what the answer is....but I do know this, I have malpractice insurance and I consider it a must have at this facility. If I were working agency, I would REFUSE assignments on this unit, too.

This is just a case of the supply clerk falling down on the job and nobody stepping up to intervene. Have your clinical instructor "ask" the charge nurse on duty where she might find thermometer probe covers. This may be all it takes to have someone step up and let the stock clerk know that supplies need to be ordered. Meantime, just continue to use your alcohol prep in between uses.

My experience has been a better base rate for LTC, but it is a harder more physically demanding job than the hospital. My hospital shift diff. was better than LTC's, but the base rate was a couple dollars less. All in all, it evened out to about the same. I have recently returned to day shift LTC for the hours MON-FRI 7-3. The work load is triple what I was doing at the hospital, but the hours make it worthwhile for me and my family.

7 what? med omissions? I'm confused. You can't be effective with your med pass until you are using your MAR as you go along. Once you get the hang of your med pass, and have a routine going then you can skim over your MAR at the beginning of your shift for any new orders so that they will be fresh on your mind in case you go on "auto pilot" and start giving out meds by memory. Not trying to be tough here, but if you are looking for a solution to med errors, there is only one.........Give meds by your MAR. As far as nurses writing other nurses up for med errors, I don't see how that can be conducive to a good work environment. That should be the RN Charge Nurse's job or the DON's job. I'd think it was your job to simply point out omissions to your co-worker so they can circle the med as not given. I'd question the agenda of nurses who run heat on their co-workers. What's their motivation?