RN's skipping vital signs

Golden_RN, MSN · Oct 15, 2019

I've experienced a similar situation, as far as patients refusing care. To improve the situation, staff education was necessary on why the care, in this case VS, are important. They techs also need education on how to communicate with patients to get the VS. Then, they have to be able to go to the RNs when a pt is refusing, leading the RN to get involved to try to get the VS. It is ultimately the RN's responsibility. I am kind of confused as to why you don't have buy-in from the DON. I'm also curious as to how the techs/RNs are charting when the VS are not obtained.

ComeTogether, LPN · Oct 16, 2019

Put parameters on the cardiac meds. If they're still documenting on paper that's likely why its easily missed.

Closed Account 12345 · Oct 16, 2019

I agree this is a problem, and it's disappointing that your concerns haven't been addressed by management. Perhaps you could suggest a chart audit to show management how prevalent this problem is. You could also file incident reports when you come across charts that are missing the last 60 sets of ordered vitals.

As a *nurse* practitioner, you know how nurses are spread too thin. If a competent patient declines to have VS taken, that's their right. If the nurses have explained why the vitals are needed, and the patients still decline, then I don't think nurses have a responsibility to beg/grovel/convince the patients to change their minds or bribe them with coffee. There's not enough time in the day to play games with patients, and ultimately, patients have the right to decline. The refusal should be documented every time.

There are 3 things I would do in your position.

1. Speak directly to the nurses. "Hey, can you go grab a set of vitals on Patient X? Thanks!" Easy. Problem solved.

2. Speak to management about revising the current VS policy. Advocate for changing the policy to say "vitals as ordered" instead of daily. Patients' care needs should drive policy, not the other way around. You as the provider are saying VS aren't needed daily for most patients; don't waste staff's time ordering unnecessary tasks.

3. If you see that a patient needs vitals taken, take them. It takes 2 minutes. You are a nurse.

MunoRN, RN · Oct 17, 2019

On 10/14/2019 at 5:07 PM, egg122 NP said:
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.

Facilities get cited for nurses acting outside of orders where that action is outside of their scope and requires an order, for instance if a medication is ordered as 5-10mg but the nurse gives 20mg. Declining to follow inappropriate orders is not allowed allowed by state licensing boards, but an expectation.

And while prescriber's orders are probably accurately described as more than just a "suggestion", RNs are independently licensed and are not required through any sort of regulatory mechanism to follow all prescribers orders, and actually are required to evaluate the appropriateness of all prescribers orders and incorporate them into their prioritized interventions appropriately.

MunoRN, RN · Oct 17, 2019

On 10/14/2019 at 7:31 PM, rn_patrick said:
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.

Maybe you could clarify what you'd like a source a on, a nurse's responsibility to prioritize appropriately? Their legal ability to decline a prescriber's order based on their independent judgment?

Nurse's should be concerned about failing to assess where assessment is indicated, not doing daily vital signs when they clearly are not indicated is not a concerning source of liability.

I'm still not sure why you feel this is an issue that needs to be dealt with in the first place, it seems as though is maybe more of a need to assert a hierarchy than it is to ensure unnecessary vitals are being taken.

Guest1130774 · Oct 24, 2019

On 10/12/2019 at 7:18 PM, rn_patrick said:
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?

I have never worked in a facility where the nurses or CNAs were lazy. However, I have worked in many where orders such as vitals end up skipped, gotten at the wrong times, or they make up the numbers.

I think the best solution is to interview the nurses and try to come up with a plan together. Pushing "Nursing Liability" can sound threatening and may add to the stress they already have.

I've seen a lot of instances where the staff are overloaded with work, but threatened by management if they get overtime. It puts a lot of stress on the staff, both the nurses and CNAs. Telling the nurses they need to get these things means they'll end up having to skip breaks or work off the clock after shift. So you can imagine there is resistance to additional work or something small like vitals. Their priorities are life-saving meds/treatments.

I can't speak for psych because I've never worked there before. If this were a SNF or LTC, I can pretty accurately tell you that it's because the staff are working off the clock already and don't want the extra work.

rn_patrick, NP · Oct 24, 2019

On 10/16/2019 at 12:35 PM, FacultyRN said:
There are 3 things I would do in your position.
1. Speak directly to the nurses. "Hey, can you go grab a set of vitals on Patient X? Thanks!" Easy. Problem solved.
2. Speak to management about revising the current VS policy. Advocate for changing the policy to say "vitals as ordered" instead of daily. Patients' care needs should drive policy, not the other way around. You as the provider are saying VS aren't needed daily for most patients; don't waste staff's time ordering unnecessary tasks.
3. If you see that a patient needs vitals taken, take them. It takes 2 minutes. You are a nurse.

I have been doing #1 with specific nurses and techs. Which has increased compliance on my high risk patients. Which is really all I wanted.

Since writing this, I did go to RN management and ask "Do we really need to do this every day." I have been told this is something I am working on. Currently facility policy is daily in the AM. I can't override that.

I have been doing that at times, for the high risk patients. The other side of this is I work with a team of MD's. I have the same role as one of the MD's. They don't do any direct patient care at all. Many times as an APN/NP you have to be careful how much "Nursing" you do or depending on the culture it can cause some culture issues and disrespect from the MD's.

rn_patrick, NP · Oct 24, 2019

1 hour ago, Anthony O said:
I have never worked in a facility where the nurses or CNAs were lazy. However, I have worked in many where orders such as vitals end up skipped, gotten at the wrong times, or they make up the numbers.
I think the best solution is to interview the nurses and try to come up with a plan together. Pushing "Nursing Liability" can sound threatening and may add to the stress they already have.
I've seen a lot of instances where the staff are overloaded with work, but threatened by management if they get overtime. It puts a lot of stress on the staff, both the nurses and CNAs. Telling the nurses they need to get these things means they'll end up having to skip breaks or work off the clock after shift. So you can imagine there is resistance to additional work or something small like vitals. Their priorities are life-saving meds/treatments.
I can't speak for psych because I've never worked there before. If this were a SNF or LTC, I can pretty accurately tell you that it's because the staff are working off the clock already and don't want the extra work.

I don't think anyone is lazy. Like I said in my initial post I was asking am I overreacting for my more at risk patients to want vitals daily. Obviously the feeling here is "something small like vitals" is not that big a deal.

Corporate SNF or LTC are the worst for wage and hour abuses. Report them and they will find all your mistakes and send them to the board. The nurses here get out on time usually, and this place is exceptionally well staffed.

I suggested the class and it died in someone's mailbox. I think you have the right feeling about how that was received.

I spoke to the Medical Director is trying to get the P&P changed. Their concern is that at 1x a week means if missed it will be possibly 7 days before they are taken again.

egg122 NP, MSN, APRN · Oct 26, 2019

You've done what you can. Just keep following up on the high risk patients like you have been and focus on obtaining the vitals/info needed for safe psych practice (whether that is orthostatics, etc). You are not responsible for the fact that the facility does not want to follow it's own P&P or change it to reflect the actual practice. Your medical director needs to buck up and do his job instead of pushing it on you (It's interesting that he has no concern about the liability that occurs when the P&P isn't followed but he feels less than daily vitals policy is a liability). Plus, like you said, there is a medical NP is responsible for the medical management, including diabetes regimens etc and should be following up with that.

Also, keep a notebook with a record of the dates, times and people your voiced your concerns with just to cover yourself.

**canoehead, BSN, RN** · Oct 28, 2019

If the patients are refusing or generally not cooperative, "sweet talking them" into vitals may play into manipulative behavior. Respecting a patient's right to refuse can be therapeutic in an environment where they don't have a lot of control.

If the patient is refusing vitals, but not prn meds, you could insist on vital signs within 24h before giving the drug. Win/win right?

CCU BSN RN · Dec 28, 2019

I would go find the CNAs or techs or nurses or whoever is actually doing the taking of the vital signs. I would tell nursing leadership you want to have a meeting or an in-service with them so that y'all can get on the same page and have some face time. I would bring snacks. We love snacks. Bagels or donuts and coffee are always a hit, and cheap.

The people actually doing the work may not understand which patients vitals are a priority to you and why, they may not understand that vitals at 6am in bed are different than at 10am in a chair. They may not know that they should try harder not to let a specific patient refuse vitals because you're adjusting medications and they could be doing something unsafe for the patient and your license. They may have staffing concerns or not be able to see the patient's orders, just doing what the RN tells them to. The timing of vitals may be due to constraints on their schedule at certain times of day. Find out what their barriers are. Really listen. Remind them that they're an important and valued part of the patient's care, and that you all got into this to help people and to work as a team.

Just my 2 cents. Management will send them a nasty email to follow orders better and then wash their hands of the issue and hope you get satisfied or that you find something new to care about. Nothing will change, you'll be frustrated, etc.