So, I'm a brand new RN, with just over a month experience in my LTC/ rehab facility. I had 8 days of training (4 on each floor), which mostly consisted of working with a preceptor. So I know a lot was missed in my training, and I am trying to learn what I've missed, but it gets so overwhelming just trying to keep up. I have 25 patients when I'm on the LTC floor, and 20-22 when I work rehab.
Anyway, I usually work day shift but filled in for someone on evening shift Sunday night. The report I got on one resident was that he'd been SOB with insp and exp wheezes, and she had given him a neb treatment. I go to check on him and he is REALLY SOB and wheezing a lot, with resp 24-28. I give him another neb treatment and it doesn't improve. He is sounding like he is working hard to breathe. Check his temp and it's 101.9, so I page the MD on call. Told him all the symptoms and he immediately advises me to send him to the hospital.
I called transport, and the ambulance company decided his symptoms were too severe for routine transport and advise me to call 911. They actually refused to take him. So I call 911, they come, and the paramedic said he was concerned he may be septic (I never found out if he really was, but that was the concern).
So today in our nurse meeting, the new DNS says we need to call her FIRST when we are sending someone unless it's a dire emergency. She says she is disappointed I sent him because we could've handled it in house, and she could've convinced the doc not to send him. While it's apparently true I could've called for a stat mobile x-ray at 9pm (didn't know that), started an IV and had meds sent stat from the pharmacy, I don't know that treating him in house would've been the safest option. But as I said, I'm a brand new RN and there is a LOT I don't know. What would you do?
To be clear, I am not in trouble and she has not spoken to me personally or expressed dissatisfaction with my performance. Just disappointment at the revenue lost and inconvenience for the family. But did I make the right choice, or no? I hadn't been told we should page her before the doc, but for all I know, there could be a memo about it posted somewhere. It is easy to miss stuff in this place. Btw, the RCM said there was no policy about it that she knew of, but she is new too.
I feel you. My unit manager is also cracking down on return to acute trips and wants to do everything possible to prevent sending a resident out. In many cases this is ok and can be safely handled in house. But there have been a few issues that even though we could technically handle in house, were very time consuming. We have 30+ residents to a nurse (upscale LTC with very low acuity patient load so it's manageable). If even one of them has a major issue that requires frequent assessment and intervention, the entire night is screwed and other resident suffer.
I I don't think all manager consider that while many resident conditions can be handled in house, we quite literally don't have the time or means to take care of them while still keeping the other residents safe and happy.
I mo think you made the right call if the resident was crumping and the treatments you had available to you were in effective. Add that to the fact the resident has been admitted and there a few days just shows they were ill enough to need more acute level care.
Could this be because he is skilled ? Many LTC facilities have a flip fit when sending out skilled residents especially if there skilled for pneumonia and those kind of symptoms can be managed in house. But how can the DON get on you for doing the wrong thing ? The DON is an RN right ? You got an order from the residents physician. IMO he must go. I'm not going against one our physician order and our DON wouldn't either. In this mans case he is severely SOB and all Nursing and medical interventions that can be taken in the facility have been ineffective and the mans SOB and running a pretty elevated fever. I do believe that this would have been one I would have sent out and notified MD later (our facility MD allows us to do this though ). We all know facilities wanna get paid and it's all about the money but us nurses have to protect our license. Yes RNs are responsible for supervising our LPN practice but in my state the LPN nursing board and RN nursing board are two separate entities and if you fail to take the appropriate action on an unstable patient your answering to the LPN board by yourself there will be no RN there taking responsibility it's you the Nurse and the board of Practical Nursing.
mrsboots87
1,761 Posts
I feel you. My unit manager is also cracking down on return to acute trips and wants to do everything possible to prevent sending a resident out. In many cases this is ok and can be safely handled in house. But there have been a few issues that even though we could technically handle in house, were very time consuming. We have 30+ residents to a nurse (upscale LTC with very low acuity patient load so it's manageable). If even one of them has a major issue that requires frequent assessment and intervention, the entire night is screwed and other resident suffer.
I I don't think all manager consider that while many resident conditions can be handled in house, we quite literally don't have the time or means to take care of them while still keeping the other residents safe and happy.
I mo think you made the right call if the resident was crumping and the treatments you had available to you were in effective. Add that to the fact the resident has been admitted and there a few days just shows they were ill enough to need more acute level care.