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.
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)
Thank you so much VICEDRN for the support! That really means a lot. :redbeathe
I'm a newly minted RN. I work in LTC. I love it, but I never planned to be there. lol I graduated in May. I work with LPNs that have been around the block a whole lot more than I have. I depend on them to HELP ME and TEACH ME. I have no qualms asking and will back them up 100%. There is no way on earth that I can compare as a new RN to an LPN that's been in the building for nearly 30 years. No way. I suppose the official hierarchy is that I'm "the boss." I know better. Sorry. I'm a little, ignorant babe in the woods. I worked as a CNA for the company before I became an RN, so I was recruited and got the scoop that they are trying to phase out LPNs. I'll cry. These women are phenomonal. And I would trust nearly any advice that they give me. Your milage may vary. I'm not going to give the same respect and deference to a new LPN. The ladies that have been there forever!? You betcha. I
I'm a newly minted RN. I work in LTC. I love it, but I never planned to be there. lol I graduated in May. I work with LPNs that have been around the block a whole lot more than I have. I depend on them to HELP ME and TEACH ME. I have no qualms asking and will back them up 100%. There is no way on earth that I can compare as a new RN to an LPN that's been in the building for nearly 30 years. No way. I suppose the official hierarchy is that I'm "the boss." I know better. Sorry. I'm a little, ignorant babe in the woods. I worked as a CNA for the company before I became an RN, so I was recruited and got the scoop that they are trying to phase out LPNs. I'll cry. These women are phenomonal. And I would trust nearly any advice that they give me. Your milage may vary. I'm not going to give the same respect and deference to a new LPN. The ladies that have been there forever!? You betcha. I
Yep- not always about the alphabet involved behinds one's name, but the years of DOING what's been learned :) Most of my nurse friends are LVNs from TX. I have RN friends as well, but I worked with a lot more LVNs, and they were GREAT co-workers. I was usually in charge, but it didn't matter. We were a team :)
I'm a newly minted RN. I work in LTC. I love it, but I never planned to be there. lol I graduated in May. I work with LPNs that have been around the block a whole lot more than I have. I depend on them to HELP ME and TEACH ME. I have no qualms asking and will back them up 100%. There is no way on earth that I can compare as a new RN to an LPN that's been in the building for nearly 30 years. No way. I suppose the official hierarchy is that I'm "the boss." I know better. Sorry. I'm a little, ignorant babe in the woods. I worked as a CNA for the company before I became an RN, so I was recruited and got the scoop that they are trying to phase out LPNs. I'll cry. These women are phenomonal. And I would trust nearly any advice that they give me. Your milage may vary. I'm not going to give the same respect and deference to a new LPN. The ladies that have been there forever!? You betcha. I
I absolutely agree with you. As some of the earlier replies stated, LNPs pretty much run the show at most LTC facilities. On most instances, I would trust this particular LPN's judgement over any other nurse in the building, whether RN or LPN. However my concern was over whether or not I could or should take orders from an LPN (who was not on the premises) and what sort of reprimand I could face if I disobey those orders and follow my own nursing judgment instead. We shall see on Tuesday when I return to work:eek:
I absolutely agree with you. As some of the earlier replies stated LNPs pretty much run the show at most LTC facilities. On most instances, I would trust this particular LPN's judgement over any other nurse in the building, whether RN or LPN. However my concern was over whether or not I could or should take orders from an LPN (who was not on the premises) and what sort of reprimand I could face if I disobey those orders and follow my own nursing judgment instead. We shall see on Tuesday when I return to work:eek:[/quote']
Print out the article on the federal standards/law...they shouldn't have a lot to say after YOU saved them from a probably violation :) They might stew a bit, but they really have no legal room for discipline...if they come up with insubordination, ask them who you are supposed to clarify something with when you don't think what's being asked is something you can LEGALLY do... I'll be sending good thoughts /prayers (what ever you prefer :)).
Only if the hospital admitted her. Otherwise, she was still a resident of the LTC. :)
I meant that the OP was no longer directly responsible for her, as when one hands off a patient at shift change. I have no idea to what facility the patient now "belongs" but I sure know I couldn't tell an ED to keep her, we don't want her.
At one building I worked in, my facility got in the habit of not taking "problem patients" back once they were admitted to an acute (usually psych) hospital. Almost like punishment at times. We had one lady with a mental disorder who, during our state survey, kept trying to talk to them (she likes to talk and complain and the surveyors new it was harmless cause she'd been there forever and they talked to her every year). After this last year, there was regime change, and all of a sudden the resident was sent to the acute psych and we were told she would not be coming back. It got so bad there that the hospitals (esp the psych) wouldn't take patients from us for a "tune up" because they figured we were dumping. Made it very hard to get help with the violent patients!
On the other hand, I've had facilities dump on me before. One facility, before we had accepted the patient, dumped 2 of them on us. These were the most aggressive, sexually assaultive patients I had ever come across!
There is another thing that bugs me, though. We have sent some residents to the ER, and when the ER gets ready to send them back, they call us and say "You need to come pick your patient up. We aren't going to send them back. If you don't pick them up, we will report you for abandoning your resident." They sent one resident back via taxi! Without telling us first. The ER had told the resident to have the facility pay the taxi when she got back to the facility. At 10pm at night when the business office was closed and we had no access to facility money. When we questioned the ER staff, they say "an ambulance is too expensive and we aren't going to arrange transport. Are you going to make the resident pay?" One of our NOC shift nurses had to drive out to the ER one night in her car to pick up a resident!
That, to me, is an extreme misuse of the dumping laws.
A resident can only be admitted to one place at a time. If sent to the ER for eval and treat, they were not admitted and therefore they return to the facility. There are state and federal laws about this plus you have to remember some payor sources (MA) have bed holds that have to be followed. If their acuity is too high, then social services and discharge planning can start with enough notice. I have seen patients admitted to the hospital and in turn the facility not take them back.
We do not allow LPNs in a charge nurse role. Actually in my area, I have yet to see a LPN in a charge nurse role. But the Wisconsin Board of Nursing is specific about the LPN in that role. The LPN is only responsible for the building for the most part.
Speaking as an RN, and ADON of a LTC facility, I don't have a clue.
I wish you luck when you go back to work. Take a copy of that article with you. Ask your DON why SHE/HE didn't call the hospital, or call you? Stand your ground, if you get fired, at least you still have your license.
That resident has no business being in an LTC, needs to be in an acute rehab at the very minimum.
tofunurse<3
11 Posts
Thank you so much VICEDRN for the support! That really means a lot. :redbeathe