specific rules and regulations in ltc/snf

ktwlpn, LPN · Apr 2, 2004

I am in a heap of trouble. Anyway, does anyone know where a nurse can find some resources re: specific rules/regs that pertain to nurses and md orders.
I applied a heating pad to a resident and was written up for not obtaining an md order. I absolutely had no idea that nurses needed an order for this; I always thought it to be a supportive and therapeutic intervention. Where can I find info as to what nurses are allowed to do utilizing their nsg. judgement vs. what warrants an md order????????????? I am totally stunned. When I worked in acute care, you did not need orders for this. I live in Massachusetts, if that makes a difference. Thanks so much in advance.

I am not sure where to find the specifics pertaining to this...I know we have orders for every little thing but not sure if it is just p and p at my ltc or regs...I will do some looking...Was it an electric heating pad? We strongly discourage there use...We send residents to P.T. for hot packs and get re-imbursed for it....As long as there was no harm to the resident I can't see big trouble for you...Just a learning experience...I certainly would not accept a written warning without a great deal of fuss....I think a verbal would be appropriate...Now you know-orders for everything...Orders to keep OTC products at the bedside to use ad-lib (if facility permits) You just can't compare acute care to ltc,can you? I'll let you know if I can find specific info.....

doobiedo, RN · Apr 2, 2004

You essentially need orders for everything in LTC.

The facility I just started working at has standing orders for some things such as skin tears, Tylenol for pain and or temp, constipation, etc and other misc. things. We srite a V.O. from MD when we need one of the standing orders.

leslie :-D · Apr 3, 2004

I am not sure where to find the specifics pertaining to this...I know we have orders for every little thing but not sure if it is just p and p at my ltc or regs...I will do some looking...Was it an electric heating pad? We strongly discourage there use...We send residents to P.T. for hot packs and get re-imbursed for it....As long as there was no harm to the resident I can't see big trouble for you...Just a learning experience...I certainly would not accept a written warning without a great deal of fuss....I think a verbal would be appropriate...Now you know-orders for everything...Orders to keep OTC products at the bedside to use ad-lib (if facility permits) You just can't compare acute care to ltc,can you? I'll let you know if I can find specific info.....

it wasn't an electric one. a former occupational therapist had given us a few 'beanbags' that were filled with corn kernels. it was approx. 18"x6" rectangular bag which i microwaved for 1 minute; shook it up then wrapped it in sheepskin. i held it to my face approx. 1 minute. i did not feel any heat being emitted but still chose not to reheat it. i placed it under her back to which the pt. immediately stated "that feels wonderful". i thought her relief to be from the beanbag conforming to her kyphotic spine, thus giving her support. when i returned to work the next morning, the noc nurse told me this pt. had sustained a blister. needless to say i was stunned. i told my DON and of course, she had to report it to the dept. of public health. it's a very involved case but when dph came, it opened up a whole can of worms. the bottom line is (1) i've been charged by the board of nsg., as well as the nurse mgr. and the DON. i've already responded to the allegations to the board, so now i have to wait. for the life of me, i will NEVER know why this pt. got burned but since i documented applying the heat, i have to take responsibility for it. it has been a horrific nightmare. but i will always maintain, that heated beanbag was not generating any heat so until my dying day, i will never know why this happened. with that being said, i have been frantically looking for specific information on what you need orders for since the board wanted me to respond to (1) why i did not obtain an md order and (2) why i did not check the patients' skin after the application of heat. thanks for listening.

CoffeeRTC, BSN, RN · Apr 3, 2004

Wow what a stinky situation..I guess I'll never apply a moist heat pack to anyone again..(even tho its prob the only thing that the resident wants and used at home.. I guess I'll need to call the doc at 3 am for the order)...

LTCs are overly regulated..I know we need an order for Ben Gay and chloraceptic lozengers.

Did you ask your DON for some info on this, she should be able to give you a copy of the regs??

leslie :-D · Apr 3, 2004

Wow what a stinky situation..I guess I'll never apply a moist heat pack to anyone again..(even tho its prob the only thing that the resident wants and used at home.. I guess I'll need to call the doc at 3 am for the order)...
LTCs are overly regulated..I know we need an order for Ben Gay and chloraceptic lozengers.
Did you ask your DON for some info on this, she should be able to give you a copy of the regs??

no, actually she royally screwed me over. when i told her about this the next morning, the first thing she asked is if there was an md order. when i replied i did not, she told me to write one (that's the can of worms i was referring to). when the dph came in, the investigator called it a system failure. so when i wrote the order for heat prn, the don told dph that "it's not within the scope of my practice to give orders" and totally denied giving me any. the investigator did not believe her; i was absolved of any wrongdoing since nurses writing treatment orders with the mds signing at a later date, had been going on for years. the flip side of the coin is back in september, i wrote a nurse's note reflecting and quoting a patient's concern. the don wrote me up for "disparaging another nurse" even though i provided legal proof that i was expected to chart anything that could impact a pt's therapeutic regimen. like i said, it's a complicated case that i am appealing, grieving and will fight this to the end (i'm not talking just about the warning) because of unethical practices within the workplace. anyway, since my record has been impeccable for several years and all of a sudden allegations are being put in my folder since this DON came 9 months ago, many things are coming to a head. and no matter where i work (i was terminated on 3/17), i will pursue this because i have been wronged. God, i really am babbling, aren't i?

KaroSnowQueen, RN · Apr 3, 2004

I'm so sorry, can't give any advice, but empathy. Some LTC's are a big old weird weird place, and that's one reason I got out of it, so many LTC's run their own way and when something goes bad, you're hung out to dry and those who run the place are there to help crucify you. I empathise completely and just wanted to wish you luck and send good thoughts your way.

FrazzledRN · Apr 3, 2004

no, actually she royally screwed me over. when i told her about this the next morning, the first thing she asked is if there was an md order. when i replied i did not, she told me to write one (that's the can of worms i was referring to). when the dph came in, the investigator called it a system failure. so when i wrote the order for heat prn, the don told dph that "it's not within the scope of my practice to give orders" and totally denied giving me any. the investigator did not believe her; i was absolved of any wrongdoing since nurses writing treatment orders with the mds signing at a later date, had been going on for years. the flip side of the coin is back in september, i wrote a nurse's note reflecting and quoting a patient's concern. the don wrote me up for "disparaging another nurse" even though i provided legal proof that i was expected to chart anything that could impact a pt's therapeutic regimen. like i said, it's a complicated case that i am appealing, grieving and will fight this to the end (i'm not talking just about the warning) because of unethical practices within the workplace. anyway, since my record has been impeccable for several years and all of a sudden allegations are being put in my folder since this DON came 9 months ago, many things are coming to a head. and no matter where i work (i was terminated on 3/17), i will pursue this because i have been wronged. God, i really am babbling, aren't i?

Not babbling....venting! Geez!! This DON is completely dangerous! :angryfire I know it doesn't feel this way now...but they did you a favor when they let you go...! You sound like an intelligent, and ethical nurse who any facility would be lucky to get! Don't beat yourself up over the blister...should heal with no harm done...if it was over a pressure point could've been the beginnings of a pressure sore and not from any type of heat..who knows...I would also feel the need to pursue it though-to vindicate myself! Good Luck with everything and keep us posted!!

CoffeeRTC, BSN, RN · Apr 3, 2004

Yep probably good to be out of that place (would have been nice to leave under better circumstances). I worked in a place like that..everytime I left work I would wonder..."what kinda crap are they gonna start now or find" Some of the staff would love to just look over my work and find the tiniest thing wrong to write up or complain about (How do these people find time to do their own work??) One nurse complained that a dressing wasn't secure enough (res had a tape allergy and wound was wrapped with cling)

Don't give up and fight it...sounds like you're a good nurse!

leslie :-D · Apr 3, 2004

the first time the DON set me up, i went to the director of human resources in our corporate office. i went to him again in november re: a pretexted, fabricated warning and now i updated him on this situation. i have left a paper trail with my concerns and his responses to me. when i told the hr director (they're located in another state and they own many facilities throughout the country) that i was not heard impartially on my appeal, he wrote back to me stating he was going to hand this over to my administrator's manager, who happens to be the president of outpt. and inpt. facilities nationwide. i am unsure as to why, but i feel i will be heard. the crap that the don/administrator have in writing to me is SO disputable and anyone would raise an eyebrow to what they've alleged. i've had several headhunters call me but i don't know what to say re: the bon hanging over my head and being terminated. and i did write to cms re: what nurses need md orders for.

CapeCodMermaid, RN · Apr 6, 2004

the first time the DON set me up, i went to the director of human resources in our corporate office. i went to him again in november re: a pretexted, fabricated warning and now i updated him on this situation. i have left a paper trail with my concerns and his responses to me. when i told the hr director (they're located in another state and they own many facilities throughout the country) that i was not heard impartially on my appeal, he wrote back to me stating he was going to hand this over to my administrator's manager, who happens to be the president of outpt. and inpt. facilities nationwide. i am unsure as to why, but i feel i will be heard. the crap that the don/administrator have in writing to me is SO disputable and anyone would raise an eyebrow to what they've alleged. i've had several headhunters call me but i don't know what to say re: the bon hanging over my head and being terminated. and i did write to cms re: what nurses need md orders for.

Earle,

Is this a KINDRED facility you're talking about? I know they have several in Massachusetts and a corporate office elsewhere.

leslie :-D · Apr 6, 2004

Earle,
Is this a KINDRED facility you're talking about? I know they have several in Massachusetts and a corporate office elsewhere.

no mermaid, it's not. if i'm allowed to say it, it's crc health that owns it.