Punished for NP decision

[davidmartindale]

Over the last few years I've worked for a company that closed the facility I was at and moved the staff to another building. In my time of being manager of the dementia unit I worked closely with a group of psychiatric attendings including a psychiatric NP. At the new building I discussed a resident that has significant mental health issues of screaming and crying. I discussed the situation with the attending NP who increased the residents Zoloft Residents poa daughter found Mom's lethargy to be concerning. Resident is a 95 year old woman. Mom's appetite declined and poa daughter had mom hospitalized and had a g tube placed and blamed the Zoloft for her changes. I am now forbidden from reporting off on unusual findings in residents without out discussing said findings first with a manager. Is it me or is this just beyond crazy.

[brownbook]

You can't talk to your NP, you can only discus patient care, needs, findings, etc., with your manager? Then what? Your manager gives you permission to talk to the NP? Or the manager relays your findings to the NP?

I would go with their plan. I think the manager is going to get tired of playing middleman (person) pretty quick.

Yes it is crazy. It sounds like they are letting the Residents POA daughter tell them how to do their job?

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

I think the daughter's concerns should have been reported to the NP as well so that the Zoloft could have been titrated a bit to amount that was beneficial to the patient without sedating her.....or try a different medication altogether. Based on the OP's post, there were indicators to suspect that the dosage was working far too well (lethargy, decreased appetite).

Granted, prolonged screaming and crying is not good for a 95-year-old heart. I agree that the OP should have reported this to the provider (physician or his/her designee [NP]). But something should have been done to address the daughter's concerns as well. Did not the daughter have input into the increase in dosage in this psychotropic medication? Here, with my mom, the nursing home called me with every initiation/change in dosage of a psychotropic drug and I had to give my consent before they could do anything.

It might be time for some new protocols at your facility. Until that happens, your manager may find herself in shoes that you once wore. So don't beat yourself up about it. The responsibility has been shifted from you to the manager, although you still have to report to him/her any abnormal behaviors. Unfortunately, it's situations like this that have to take place before the need for protocols or protocol revisions are considered.

[Cowboyardee]

It's not clear to me exactly what your job role is at this time. But if it is still your legal responsibility to refer important issues to a provider (as is the case for most nurses), then it is 100% inappropriate for you to have to clear it with a manager first before referring a concern to a provider.

Here's a scenario: in your current role, imagine you came across a life threatening condition. You report it to your manager, and she tells you to do nothing. Are you liable and/or is your license in jeopardy if you obey and fail to report the situation to a provider, resulting in a patient's death? If so (and it likely is so), then ordering you to defer to a manager before contacting a provider is inappropriate. Don't do it.

Also, best I can tell from the picture you painted, your judgment seemed fine in the first place. In fact, your judgment and the NP's management seemed so fine that I wonder if I'm missing some crucial detail here. Are you operating in some role where you wouldn't normally have much input in a patient's management or care? Is the NP in question involved in some kind of turf war with a psychiatrist? Does your facility normally penalize its employees every time some patient's family member has ill-informed and erroneous ideas about their loved ones' medical care? What gives?

[vampiregirl, BSN, RN]

During my time in SNF management, I became familiar with state regulations regarding psychotropic meds. I'm guessing these vary from state to state. Often the issue isn't that a med isn't inappropriate for the patient, it's that there is lack of documentation to substantiate it's use.

The facility I worked at had a process in place that included requirements of documentation of notification to the POA of any med changes, a way of communicating psychotropic med changes to the appropriate members of management and a review process in place to observe for effectiveness and/or side effects of any med changes. There was also a monthly meeting that included representatives from the psych provider group and the pharmacist to review every patient on psychotropic medication. Was this a pain to complete all the required steps and documentation? Yep. Did it serve to protect the patient and the staff? Yep.

If the opportunity arises, maybe consider initiating a conversation with your manager about reviewing the current process.

It also could be the patient happened to have a decline in condition concurrent to the medication increase. Sometimes family is not in a place to accept decline in condition and react aggressively without consideration of the patient's wishes and/or directives in place.

[Buyer beware, BSN]

You can't talk to your NP, you can only discus patient care, needs, findings, etc., with your manager? Then what? Your manager gives you permission to talk to the NP? Or the manager relays your findings to the NP?

I would go with their plan. I think the manager is going to get tired of playing middleman (person) pretty quick.

Yes it is crazy. It sounds like they are letting the Residents POA daughter tell them how to do their job?

Rule #1. NeverEver interfere with the cash cow known as the patient.

This is the poa's tacit threat that is heard loud and clear. But wait there's more!

Yes I understand that this play is not easy to do on the part of the poa, but who the hell wants to deal with the Department of Children and Families when they come knocking investigating an allegation of elder abuse.

You can never underestimate the leverage value of the dollar coupled with the threat of abuse which last time I looked is considered a felony, at least in the sunshine state.

I know what some may be saying right now: "this guy is being his usual cynical self." Oh, well.