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wrigp

wrigp

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  1. Fair warning this might be a long post but I'm having several issues with my current employers policies that were recently implemented. I work at a outpatient psych clinic as a LVN for the past 5 years. About a year ago I was transferred from one clinic to another that utilized MA's to a much larger degree than my previous clinic. I have another RN on site who in December passed her NCLEX and this is her first job. No previous experience in nursing. Our clinic also has 6 MA's who complete vitals and state measures prior to seeing the providers. Our OP's have always been confusing or even conflicting, but until recently aside from mentioning it to our nursing management or asking for clarification. About a year ago MA's at my current clinic also started to really administer long acting anti-psychotic IM injections. Since then there has been several medication errors, including a wrong med to the wrong patient. Luckily we have not experienced any negative outcomes and all incidents were always reported properly and documented. There were several things I ended up addressing with the MA's about their injection of LAI's such as double checking order, last injection, last site, and most importantly the vitals as they would just administer it if the provider ordered it. Once it was given to a client who was older, had a recent history of falls, and BP was 86/52. Anyhow, until recently, unless seen by a prescribing provider first, MA's were not allowed to administer long acting anti-psychotic IM injections. As of this past week MA's are now allowed to give LAI IM injections even if they don't see a provider as long as they follow the protocol. I'm very very concerned about this because their protocol doesn't address a lot of the things that myself and the RN do when we see the patient in between the providers. They don't check pulses manually and instead use a pulse ox, which would lead to a missed arrhythmia (something I encounter at least once a month if not more), they only address suicidal thoughts through a screening tool, they don't address potential medication changes from other physicians, potential hospitalizations- both psychiatric and medical, medication side effects such as EPS or TD which I frequently have to have the RN come in to complete an AIMS due to new/worsening side effects, no symptom changes, AVH, drug/alcohol use etc. They basically take the vitals, which at least the BP is a manual check, have the patient do a suicide screener, admin injection based on 5 rights, document and then the patient can leave. Another issue that I have with it is that just the RN, APRN, PA, DO, or MD has to be onsite for them to administer this. Now in Texas an RN or APRN are not able to delegate tasks to UAP except in certain settings and never an IM injection. I believe this is a very unsafe practice to have that is sanctioned by and signed off on by our nursing supervisors and the medical director. The RN and I have been talking about this issue extensively. One question is if just she is in the clinic then isn't that delegation? The policy states, "Ensure that there is another medical staff member (RN, PA, APRN, Psychiatrist) on site for consult if necessary." If the RN has to be there for consult is that delegation? As it stands right now the RN trains and certifies competency for MA's when hired, but the delegation is completed through the MD who is never on site. The only provider we have that isn't an APRN is a DO who is only there 1 1/2 days per week if he hasn't taken off. Another issue is the overall new company protocol for injection administration that is the responsibility of MA, LVN, RN, and Prescribers to give injections either in the clinic or our field RN's. In the procedure it states the hold injection and consult with Prescriber (MD/DO/APRN/PA) if any recent changes were made to a patient's medication regimen while admitted to an inpatient program, if the patient has obviously altered mental status and is unable to consent to injection, stiff or rigid muscle tone, psychiatric hospitalization since last injection, if patient has abnormal vitals, recent hospitalization, medication changes or symptoms of tuberculosis. There are other ones, but those are the ones we are questioning. If the MA is giving an injection without the provider seeing the patient, how are all these to be addressed? An MA is not trained to do assessments, the only thing defined is abnormal vitals protocol which is used as a reference in the protocol for them to look at. I've asked many of them and they don't know what would be an indication of someone not able to consent for injection or if their mental status is altered. With our set of population the RN and I frequently have to go back and forth with each other if we haven't seen the patient in awhile and the other has to see if something we noticed was new or has been addressed with the provider before. We also have a OP that states they can give initial LAI injections. Now it is my understanding and firm belief that no UAP should ever administer the inital dose, either orally or IM, of any medication. EVER. Every nurse I discuss this with also responds the same way. Our emg medication administration standing orders were last signed on 11/2017, which besides the Texas Board of Medical Examiners defining that a standing order can only be good for 1 year, we have a OP that states the same thing. Those standing orders are also ambiguous and state things like Glucose 4G Fast acting tablet chew 1 tablet by mouth as needed for hypoglycemia or Diphenhydramine 50mg 1 tab by mouth single dose as needed for anaphylaxis or extra pyramidal symptoms. Now MA's are responsible for providing care under this OP. So aside from the fact that we don't have a updated standing order, therefore no true orders to administer (I just brought this up at our medical staff meeting on Tuesday and was told it would be addressed, however, it still has not.), but it does not define hypoglycemia nor are MA's trained to know what anaphylaxis or EPS looks like to give those medications. I have several other issues with OP's conflicting on what duties are allowed and what duties are not with the MA's and nurses. With all that said. I have in the past been targeted by management when I spoke up for patient safety and was harassed, then retaliated against when I reported it to HR and finally the EEOC before I was left alone. I can't not say anything about this and the RN also agrees with me. She has called TBON and left a message to have someone call her back but was told it could take up to 5 days so I thought I'd get ya'lls opinions. I'm not going to request a peer review because it wouldn't be unbiased and it would put me on everyone's radar again. Are these issues that we can report to the board for unsafe nursing practices? Can you report a company like that? All policies and protocols are signed by Nursing Admin staff. Is this anything that the board would even care about or would they say that they don't have any over site on these issues? If not TBON who else can I report this to if there is anyone? Health and Human Services? I'm not going to leave because that would not solve the problem. I am tired of all the nurses leaving our agency because of these things but no one is standing up to fight them. Leaving doesn't stop it, leaving just lets them keep endangering a population that is already open to abuse, neglect, and exploitation. Any help would be greatly appreciated.
  2. wrigp

    Lone Star Fall 2019 LVN

    Hello all and congratulations on those who got in. I’m currently an LVN in Dallas and have been looking for a program for awhile that I can work around my daytime work schedule. I read that the program at Kingwood was partial online and skills/clinical weekly with an instructor, however, everything I’ve read on here as far as the schedule seems to indicate that that information is wrong or is a different program than y’all are talking about. Is there anyone who can elaborate on this?
  3. wrigp

    Va Dallas hiring

    I was just curious how to get hired. In the past I had submitted several applications without being forwarded. Now that I have more experience I keep looking on USAjobs.gov but there aren't postings or if there are it's not open to the public. I have read that the best way is to contact a nurse recruiter, however, I can't seem to find out a specific number to call. Any help would be appreciated!
  4. Quick questions for all the psych nurses (LPN/LVN, RN, BSN or anyone else who wants to chime in :) ) I'm currently a LPN/LVN at a local community mental health clinic in Texas. Until about 2 weeks ago I would see patients in between doctors visits. The MD's does this because his schedule is 3+ months out due to his large case load. If it is someone who isn't stable then the MD's will just reschedule the person with them in 2-4 weeks. Both MD's wish the patients to see a nurse in between because anything can happen in 3 months. During the visit with me it is a focused assessment based on the current needs at that moment in time. Most patients might not be sleeping as well as they were, or feel like a medication isn't working was well as it was, and others simply just need refills until the next MD visit. If issues arise or refills are needed I would staff with the MD who would decide if anything needed to be changed based on what the patient informed me or MD's known history with the patient. That would then get relayed back to the client. If client had become unstable or needed a more in-depth assessment of the situation at hand the MD would come into my office and visit with the patient face to face. Either way I would take a verbal order for the new medications/refills and call them into the local pharmacy to fill. The MD would then sign off on the verbal order after my charting and documentation was done. Recently I've been told that it is out of my scope to do this and have had my job duties changed to just seeing patients who receive injections. Now the same assessment is done with said injection clients, however, the supervisor higher up said that these would be ok because they were stable patients due to injections. Which in of itself I could argue that they aren't which is why they are on injectionables to begin with but that is a side argument. My question is in the above setting is this a unsafe and out of scope practice for a LPN/LVN? The assessment is focused. The data obtained is relayed to a MD who then interprets the data to determine interventions needed. Orders obtained verbally and relayed to patient then called into pharmacy. If client is unstable or further assessment is needed care is then taken over by MD directly. I'm just confused why this is being done. I have searched high and low for something to point me into a unsafe or out of scope area. I don't want to work out of my scope by any means but I if I don't understand how it is out of my scope, if it is, then how can I possibly avoid this down the road? I've as the supervisor in question and I just keep getting told that it is out of my scope, that the patients are unstable etc. Which is not the case for our clinic. The RN on site even agrees that the patient disease processes are predictable in nature and she doesn't understand it either. Thank you in advance!
  5. wrigp

    LVN Scope in Texas

    I have a few questions about our scope in Texas. I'm currently working at a community mental health clinic and our DON and another ADN administrator are stating one thing and I'm not finding the support for this on BON's website like they are saying. The doctors are even disagreeing with them. (On a side note we don't have a EMR at this point. It is to be rolled out later this year but apparently they have been saying this for over 5 years now.) 1. BON has ruled that standard abbreviations for the sig on RX have to be typed out. Now mind you we have policy and procedures in place for medication documentation/administration. No where in there are specifications for what abbreviations can or can not be used. The doctor's even stated that Texas Board of Medical Examiners do not mandate this so why would TBON? Its my understanding that if the board doesn't take a position on the matter then it defers to the facilities Policy and Procedures. This is not addressed in the policy and procedures. My position on this, as well as the doctors and the other LVN, is that it is more difficult to read. This is only in regards to writing orders for record keeping purposes in the chart. This is not instructions given to clients. Ex: Lith Co3 300mg 1 po BID needs to be written out Lithium Carbonate 300 Take one pill twice a day. 2. In our particular clinic we do not have a RN on site. Most other clinics do. The physicians act as our direct clinical supervisors. In other clinics an RN sees the client for a nurse follow up and the LVN's only admin injection or fill pill boxes. Since we do not and have not had an RN in this office for over 5 years, myself and the other LVN do all of the above. We do a focused clinical assessment as a follow up to the MD appointment approximately 3-6 weeks later. Our clients mental health is very predictable. We have a form that we use during said visit where we document all the appropriate information collected during the visit. My question is this: When we complete a focus assessment for a known predictable illness for a client and there is no change in said client's condition from previous visits do we have to spell out all current symptoms to the MD prior to them giving an ok for medication refill? According to the TBON position: "The LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes and patient-centered plans of care that are developed in collaboration with patient, their families, and the interdisciplinary health care team. The LVN participates in the nursing process by appraising the individual patient's status or situation at hand. Also known as a focused assessment..." The doctors don't want to know that the client is still experiencing SI that are fleeting with no plan/intent and has been that way for years. The doctor doesn't want to know that ongoing issues with AVH are still presently active with no change in intensity/frequency. The doctors want to know what has changed from the last visit, if the medications that were changed have improved the symptoms they were targeting. If nothing has changed they always ok the refill. If something has changed or symptoms have increased we of course notify the MD about this and either they speak with the client directly or change medications during the consult and we inform the client. This has been going on for 6 years with one LVN and 2 years for myself. The reason I'm questioning this is because of a small TBON statement that states that the RN: "...Analyzes assessment data to identify problems, formulate goals and outcomes, and develops nursing plans of care for patients and their families." The reason this has come up is because they do not want us to use our instant message system to let the doctor know there is no change in symptoms and client is requesting refill of medications prescribed at previous visit. They want us to type out exactly what the client said. I understand that it is my license if something happens and to CYA I would need to place all that in there. I just need an interpretation of the boards stance. Can I or can I not determine based on my focused assessment if the condition has changed?
  6. I was wondering if you could do this working full time? With the hybrid classes and a employer willing to be flexible with my schedule I think its possible....just need confirmation. Also what courses are left to take if you are able to test out of the 3 classes to start in the Summer II Mental Health course? I have to retake A&P 1/2 because they are older than 5 years but I'm not worried about it grade wise. My science GPA will be a 4.0 and my over all GPA is around a 3.9. I've been an LVN for a few years looking for a bridge program that will allow me to work full time. Honestly didn't think it would be this difficult to find one when I chose to do the LVN route and I needed to start working sooner than 24 months. Any help or info would be greatly appreciated!
  7. wrigp

    Allegany college of Maryland

    If all else fails you could just travel to dallas or austin once a week. The 2-3 hour drive would be worth it since according to the handbook they want you to do 10/hrs per week. Maybe stay two nights in a row and pull two 12's. Do you know which hospitals in Dallas they are affiliated with?
  8. wrigp

    AMC (Allegany College of Maryland)

    Really? With which hospital and where did you get this info?
  9. wrigp

    AMC (Allegany College of Maryland)

    I've just mailed off the last of what I had. USPS will get it there by Tuesday so here's hoping everything goes well! Let me know how things go for you. What state are you in?
  10. I've seen a few people ask if others have gone through the LPN to RN online program without much success on obtaining info. Just wondering if anyone out there has gone through the process, either being accepted or not. I'm currently trying to get in the July 1st deadline however communication with this particular College doesn't seem to be as rapid as other schools. Any insight would be great!
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