Questions about company OP for Nurses and MA's in Texas

[wrigp, LVN]

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.