RN's skipping vital signs

[rn_patrick, NP]

Hello. I'm an APN/NP working at a Psych Hospital as the psych attending. Let me tell you what's happening and can you tell me if I am overreacting? I wanted to edit this down so it's not quite obvious if someone else from that facility is reading this who I am, and where I work.

Patient's are ordered vital signs once a day as per P&P. Most of my patient's are "Chronic Stable" I don't actually think they need the vitals done daily for most of them. This is the P&P right now.

We were getting low numbers and then it turned out the CNA/Techs were doing them with the patient in bed early in the AM.

We have a few that refuse, so when I inherited one or two of them we had no vitals for 2 months. Yes 2 months. I've been working on that.

I also have one or two delicate patients, one with uncontrolled DM2 (A1c 11-12) and three HTN medications, and another on very heavy psych meds that the vital signs were not being done consistently. Ordered daily and then 2-3 times a week being done, and the other patient three times a day and being done usually every 2 days or so. They are both challenging patients, but usually can be convinced with coffee or some attention.

I've gone to the DON about this but it's still not being done. I've been coming at it from a Nursing Liability standpoint but I feel all I am doing now is annoying the staff Nurses. DO I sound like I am overreacting?

[Nurse.Kelsey, BSN, RN]

Sounds like they do what they want. If thats not the case then maybe they simply cannot get vitals on these patients as often because of patient agitation... in that case they arent voicing to you any special considerations , such as agitation, at play.

[rn_patrick, NP]

I can usually get the patient to do the vitals for me. We also have a new RN who is more motivated and is able to get them also.

I very much as a former staff nurse at a different facility appreciate the patient is too agitated to do vitals. The issue is the patient had no vitals for weeks or months and the order is daily or TID and it seems people are like "Meh" so what?

[Nurse.Kelsey, BSN, RN]

Lay down the law??? Idk .. It feels like staff doesnt respect your authority.

[rn_patrick, NP]

I've tried that. I was more thinking as a staff nurse I would not disregard orders or at least document why I could not obtain the vitals. Maybe all RN's don't feel that way?

[MunoRN, RN]

There's nothing inappropriate about nurses prioritizing appropriately, that's actually a requirement of the license.

First we should clarify that the term "order" is a misnomer, a prescriber's order is an addition to the plan of care, and just like contributions to the plan of care from any other source, it's subject to appropriate prioritization, and typically there will be things that don't 'make the cut', to characterize that as 'disregarding orders' is not correct.

If you feel the plan of care is being inappropriately prioritized then you should make the case for why daily vitals should be prioritized over other aspects of patient care, although you don't seem convinced of that yourself, and generally daily vitals are not indicated for the circumstances you describe.

[rn_patrick, NP]

On 10/14/2019 at 4:43 PM, MunoRN said:

and just like contributions to the plan of care from any other source, it's subject to appropriate prioritization, and typically there will be things that don't 'make the cut',

I'd like a source on that. Especially when I read that failure to assess and failure to report a change of status is one of the leading reasons RN's get sued.

Overall I agree with you about the vitals not being indicated daily. That is what their facility P&P states. Or I would cut it back for most of them to 1x a week.

I'm making that case but nothing seems to be happening.

[egg122 NP, MSN, APRN]

A provider's order is not a suggestion. Facilities frequently get cited by the department of health for not following orders. Refusals by patients or inability to obtain vitals can be simply documented in a nursing progress note or the provider should be notified. Just keep a notebook of with written notes with dates and times that you've spoke with nursing leadership and other administrators about vitals not being taken for months- that is unacceptable.

On the other hand, it does seem that many of the daily vitals seem to be unnecessary. Can you lower them to weekly or month BPs for some patients? If a patient is on oral anti-hyperglycemics only, scheduled blood sugar checks generally are not indicated per current guidelines. You can justify this in your note by citing the sources like the choosing wisely campaign. This should be discussed as a team though if the thought is the monitoring is excessive, not just ignoring the order and refusing to engage the provider as seems to be happening here. It also seems that the policy would need to be updated as well to reflect the new practice. I think it may be an uphill battle for you but not impossible.

[rn_patrick, NP]

That one person with the A1C of 11-12 is on Lantus. I'd be fine with her getting VS daily.

I can't find a set of solid guidelines "This is how often you do vitals..." I'd be happy with Admission, 3x days after admission, then once a week, UNLESS on Anti-Hypertensives, good medical reason, starting a new medication, or Medical or Nursing judgement. Writing my own seems too risky.

I'd like to see refusals documented. Which they are not doing. I'd like to see responses to PRN's documented as well.

The Medical NP has mostly correctional experience, where I guess the standard of care is lower. He knows his stuff and he's been supportive which is good.

[egg122 NP, MSN, APRN]

Do you have a chief medical officer? What do they say?

[rn_patrick, NP]

"Thanks for taking the lead on this..." I'm going to go back to him and ask if he just wants me to drop this or to work this up. I asked the question since I may be pursuing something that nobody really cares about.

[egg122 NP, MSN, APRN]

I would take it further and outline the support you need from him if he directs you to pursue it further.