Background: I work in a skilled rehab nursing facility. I have been a nurse for 9 months. This is my first and only job as an RN. Most shifts I am the only RN on the floor, responsible for close to 100 pts. My day supervisor is an LPN. She leaves by 5pm then its me for the entire building caring for my own 25 pts plus overseeing 3 LPNs and the other 75 pts in the building until 11pm. I am not a supervisor.
I had a pt today that has a hx of ALC, going AMA, and head trauma. She is a very acute pt with a PICC, 2 jp drains and psych issues to boot. Today she had an episode where she was sitting in her chair talking with her family and all of a sudden her eyes rolled back, and slowly fell to to floor from her chair. When I found her she was on the floor unresponsive, limp, pupils not reacting but alive. VS were normal. Gave her some o2 and stayed with her until medics arrived. Sent her to the ER for eval and tx.
Meanwhile I am the only RN on the floor. My "supervisor" is an LPN and was not in the building. She called me from her home and told me that our DON told her to tell me that if ER does not admit her, that we ARE NOT TO TAKE HER BACK TO OUR FACILITY due to her acuity and hx. So I get report from the ER nurse who says that everything came back negative and they are ready to send her back to us.
Problem: She was never officially taken from our care. She was sent to ER for eval and tx only. I felt if I had followed the instructions of the DON (via telephone from an LPN) that that would be pt neglect and did not want to be responsible for turning away a pt that I had already accepted care for. So I went against orders from my DON and accepted her back into our facility.
So my questions are: Did I do the right thing? Could I have been charged with pt neglect had I not taken her back? Isn't it out of scope of practice to for an RN to take orders from an LPN? Can I get fired for not listening to my DON?
I never actually spoke with my DON and I never heard the words from her mouth. She called the supervisor who is an LPN to tell me "don't take her back." I called my DON several times for a clarification and left several messages but no return call. I felt I made the best decision at the time. I am worried about ramifications next week from DON for not following her orders. but I NEVER HEARD FROM HER DIRECTLY AND SHE WAS UNAVAILABLE!! I know our facility can get into trouble for not have a supervisor in the building.
I am worried about getting fired. My thought at the time was "I would rather be fired than to loose my license." I feel like my DON should have been the one to call the ER and tell them we were not taking the pt back and it was not my place to do that. I feel its was unfair for her to put me in that position. I am sick to my stomach over this. Please any honest advise would be appreciated thank you.
I feel better about my decision after reading that article. My goodness I had no idea that "dumping" was that common of a practice. Its sad really. I'm still bothered that my DON put me in the position she did not calling ME DIRECTLY with the orders and not being there to answer questions when I needed her.[/b'] But I do believe I did the right thing and I just hope for the best when I go back to work on Tuesday
Trust me, that was purposeful. She was keeing her hands clean. Had you not accepted pt back and the facility caught he// , you can be sure that you would have been the first one under the bus.
Good job and excellent judgement on your part. I know it wasn't easy with all the push back from senior staff.
I love LTC centers "dumping" patients on my ER and refusing to take them back. I clear my patient load and start the phone calls...
I take great pleasure in contacting the state offices for medicaid/medicare to investigate you and shut off your funding. On the weekends I have a state ombudsman to intervene and advocate for residents "not able to return" and have gone as far as to remove/deny CMS funding for the facility as well.
I have been responsible for multiple fines levied on nursing homes and have completely shut down 2 centers for stupid decisions, poor care and neglect. (Soon to have a 3rd attempting pending appeal from another jugement by US Department of Health & Human Services)
There better be a significant change in level of service that exceeds your centers ability to care for patients or you're looking to be out of business soon. Dumping is horrible for the patients and families that entrust their entire care to you and your staff. Be careful about deciding who you deny returning to your facility.
LPN, RN, DON??? I don't care where the order comes from. I don't play that game...
I love LTC centers "dumping" patients on my ER and refusing to take them back. I clear my patient load and start the phone calls....
Not to derail the thread, but this does go both ways. I'm sure from an ER stand point you don't see that but I can't tell you how many times a discharge planner will "sell" us this sweet little old guy only to get him and he is a complete wild cat ready to punch everyone around him including other residents, trying to elope, etc on 100 different psych meds that mysteriously weren't on the original MAR when we agreed to accept.
I do agree with you tho. No matter who does the dumping it is extremely unfair to the patient and their family. I think it happens because resources for these tough patients are so limited.
I'm just a student so ya'll give me some schooling please... :) Where would the patient go if not back to facility? What if they didn't have living arrangements?
OP, good for you for doing the right thing. No matter what happens at your job next week, I think you can sleep well at night and that's what matters most. If you end up shopping for a new job, then I think this story (whether you tell it or not) is proof that you are ethicall nurse if nothing else.
Best of luck to you and sending you positive vibes.
(and no, in this state, I would not have taken orders from an LPN or taken the order that you described without clarifying it first with the DON)
I'm just a student so ya'll give me some schooling please... :) Where would the patient go if not back to facility? What if they didn't have living arrangements?
That's the issue with the dumping laws. The nursing home in this situation would be violating federal law if they didn't take them back because that is their residence at the time- even if temporary...UNLESS they sign out of the LTC (would be against medical advice, and the person would have to be able to act on their own rights and make their own medical decisions) It gets complicated :)
First of all i nmy opinion an LPN should NEVER be supervising an RN or functioning in a supervisory role. And I have NOTHING against LPN's (I was one for 4 years). LPN's can NOT take a verbal order. I think you did EXACTLY the right thing!
In many states they can, and if they're the ADON in an LTC, they're higher up on the food chain....
A facility I've worked agency shifts in is facing this now. After this facility admitted resident A with an extensive psychiatric and unknown at the time, a violent criminal history, the resident had a major psychotic episode. Resident A was finally able to be taken out with police escort to the ED. When it was time to be discharged from the ED the facility refused and are being charged hefty penalties for not going thru proper channels. I'm not giving all the details obviously but if you knew the whole story anybody would see that the facility was clearly in the wrong. They were so concerned about putting a warm body in a bed during a time of low census they didn't do their homework.
Re the OP, the DNS is quite the sneaky winch. I would be seeking a new employer ASAP. You absolutely did the right thing.
Specializes in Respiratory, Cardiac, ED, Maternity, Ped.
in new york state an lpn can never take a verbal order. also can not hang blood or blood products. can not initiate a medicated drip. can not hang the 1st antibiotic. also can not do the initial assessment of a patient
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Hospice Nurse LPN, BSN, RN
1,472 Posts
Maybe not where you live, but here LPN's take v/o all the time.