SNF/LTC new nurse needs advice

by Bunnybop Bunnybop, ASN Member

Specializes in Medical Surgical.

Hello all like many the SNF/LTC facility I am working in did not offer much of an orientation like I hoped. I find it very difficult some days because nothing is written down. There are no manuals or protocols etc. We're extremely short staffed, half the time I can't find a supervisor or my GNA. I ask many questions but not all of the staff here wants to be bothered by my inquisition of questions. I work 11-7 and I miss out on a lot of the learning experiences in the facility. A couple questions I'd like to ask (and please excuse my rambling and idiocy in advance):

What medications absolutely must be given daily? I know this sounds silly, but when I first started working here, if a person's medication wasn't in yet, a nurse would "borrow" the medication from someone else. The state came and there was an issue with this of course, and the DON said that was a big no no. Also there were many times when a new order was written in the MAR, but the medication took a day or two to get to the facility. Nurses were circling that date that medication wasn't given, so the DON said the start date needs to be when the medication arrives. The day after I was told about this I pressured into working 3-11. It was crazy, I was moving the whole shift trying to do my med pass & tx's... and I got to a patient who had a new order for Warfrin. It wasn't in yet from pharmacy and I skipped over it. Looking back I realize that was a huge error on my part. I should have went to the omnicell and tried to pull that medication or even "borrow" it from another, but I was so flustered I had a massive brain fart. So what medications would you say MUST be given?

What should I be looking for before I send a patient to the ER? I really feel there should be some criteria written down here somewhere!

What would you include in a good progress note?

For the night shift workers... when your checking your charts, what kind of errors are you looking for?

Thanks in advance!

NutmeggeRN, BSN

Specializes in kids. Has 39 years experience. 8 Articles; 4,560 Posts

Whatever is scheduled should be given...that said, there should be a an e-kit from where you can pull a dose or two from. Borrowing is a no no, (not to say that it is does not happen on occasion). It is frustrating because i have been told we will be held accountable if there is a missed dose. So I as the perdiem, who has not been there in a week or so, becomes accountable for the dose that the full time people or regular part timers did not order on time......irritates me to no end.

Mn nurse 22

Mn nurse 22

103 Posts

We have an ekit and local pharmacy that we use for the first few doses of meds or we specifically have the md write "when available" if it is something that can wait for a few days.

If that doesn't happen we have to call our on call md for an order to hold the medication until delivered from pharmacy.

We also have a list of "criteria for immediate physician contact" that gives us a guideline for when to call the MD.

Systolic BP >200

Pulse >120 or

Temp >101.4

Chest pain

uncontrolled vomiting or diarrhea


and more

A lot is basic nursing but the parameters give us a good reference and keeps us all consistent.

I rely on families to help make decision for hospitalization. A lot of them want comfort care only so we would only send those patients out if we suspected a broken bone or critical incident. Other families want aggressive treatment so we send those patients out more frequently.



Specializes in geriatrics, hospice, private duty. 268 Posts

What medications absolutely must be given daily?

All medication MUST be given as ordered. Unless it is PRN, it must be given daily as scheduled. If it is not given, it is a med error. "Borrowing" from another resident is technically insurance/medicare fraud and hence a big no-no. Your facility should have e-kits (warfarin is almost certainly in the e-kit). If a med isn't in the e-kit, you can call pharmacy and get meds from emergency back up. If there is no way to get the med there to be given as scheduled, then you must call the MD and let them know. They will usually order to hold it and/or give a one time dose of something that is available in the e-kit. TL/DR: if a med isn't on the cart: 1. check the e-kit. 2. Call the pharmacy. 3. Call the doc if med unavailable through e-kit or pharmacy.

What should I be looking for before I send a patient to the ER?

Too many specific scenarios to list! Basically any change of condition from the patient's baseline should be reported to the MD and the MD will decide if they want an ER visit. So you will call the doctor, notify them of the change in condition and they will order the ER transfer (or they may opt for labs, xrays, meds ect.). If the patient is unresponsive, coding, or in a life threatening situation, our policy is to call 911, get them out, and then call the doc after the fact. On the other hand, if the change in condition is minor, we wait until morning to call the doctor. TL;DR: In most cases except the most emergent, the MD will be letting you know who and when to send to ER (though you pretty well know who will be going out based on s/s).

What would you include in a good progress note?

Depends on what is going on with that particular resident. I use my head to toe assessment cheat sheet as a guide:

There is also a great tool floating around on all nurses that deals with charting on specific issues called "daily skilled documentation guidelines" that I also use but can't find a link to at the moment.

Basically if there is anything going on with a resident (UTI, URI, ABT, PEG, FOLEY, TRACH etc) you will want to chart about it.

Good luck!



Specializes in LTC. 664 Posts

Find a new nursing home, that sounds like a very dangerous facility



121 Posts

Not sure what State you are from, but if we can't give a med and if the patient is not his own decision maker, we MUST call the Dr. for an omit order.



36 Posts

Generally, there is a protocol in place for emergent vs. non-emergent issues. Generally at night, when you are more than likely going to get the on-call doc., you have to ask yourself: what is the doc. Going to do? Ask yourself, is the patient symptomatic or asymptomatic? Would monitoring be a better option rather than calling? Keep in mind, calling a doc. Is not wrong, but eventually you want to come to a point where you can weed out the 'should I call' vs. the 'I should call now' situations. Second, medication administration is important, especially considering the type of med, and the patient'a acuity level. Jantoven is prescribed to thin the blood, keeping in mind the concern is for clots, you can kind of put two-and-two together on its importance. The key that I will stress is that nursing is a learning experience. You will not be perfect, but, with time you will notice a general trend towards trusting your gut and knowing the right decision.

Gooselady, BSN, RN

Has 23 years experience. 601 Posts

What medications MUST be given daily? is actually a question outside your practice -- but of course as a nurse, we know these things because we're nurses.

The 'take away' for you is that you follow the MD orders, period, end of story. It lets you off the hook, and simplifies your life (and honey, you need it considering where you work!)

If it says daily, then it's daily.

If the med is not available yet? Put 'not available' in the MAR or proper area for comments.

That's it. Keep it simple.

You will send yourself off on a wild goose chase otherwise, and you don't have time. It is beyond your personal control that the Warfarin was unavailable, that's on the pharmacy and facility in terms of 'responsibility'. Keep it very, very simple. The DON says 'no no' to borrowing other meds? Then don't do it (or do it very, very carefully cuz you could mistake swapping a 25mg for a 50mg with the kind of pressure you are under).

We're instructed to THINK just like you are thinking, but on the ground, in your kind of facility, keeping it SUPER simple, by the book, to the letter and if a med's unavailable -- oh well. Next patient!