Sucide lies: is it CYA or blaming?

[Tiffanybaybay]

So I had a pt this evening who was suicidal. Blatantly suicidal. He was found in his home with a gun drinking and saying he wants to end it. So he went to the Psych lock down part of the ED and when they attempted to medically clear him there by doing his labwork, they were all out of wack. His sodium was critical, liver enzymes all sky high, glucose in the 40's.

Needless to say he was promptly sent to the medical side to be treated. We were short techs to sit and watch him for a 1:1 so the nursing supervisior sent a tech to us to sit with him, just in case. Well since he was the only pt I had the charge RN pulled the sitter to work the entire dept because we were short techs. I didn't complain but to cover my butt I charted that he was "within the sight of the nurses station, appears calm and cooperative, contracts of safety, charge RN aware."

Within a few minutes I got a call from my charge RN who had been looking thorough my notes. He says that he didn't like it that I implicated him in my notes. He said that if anything were to happen this note would place the blame on him. *****

I charted that because I'm just a staff RN, I have no say in what staff goes where. However if something were to happen, I wouldn't want someone looking at the chart saying, there is an order for a one to one here, why didn't you follow those orders?

THEN the nurse sitting next to me said I should have NEVER charted that. She said, that's like the first thing you learn in school. Pt's are NEVER on a constant observation. They are only on that if they are actively suicidal. I said, but they found him with a gun saying he wanted to end it. Then she said, but constant obs is like if you're preventing them from killing themselves that moment. At any other time when they are calm it's not a 1:1. You should never say that.

WHAT IS THAT?! I've been at many facilities and they've mostly had 1:1's. Not to mention the order clearly says 1:1 suicide watch. The hospital protocol says that someone must be within arms reach. A different RN stated that 1:1 isn't even legal, it's just something hospitals do to protect themselves. Am I crazy? Did i just make this up? Was my nursing school THAT BAD that I missed that lesson? Was she being rude?

SO now my charge is ****** at me thinking I'm trying to blame him if the person off's themself. What do you guys think? Was i doing too much? Was I right, was this CYA? OR are they right that as long as the pt is in view of the nurses station that is good enough? If this were to go to court would i be justified in saying he could be seen from the nurses station or was it prudent to say I did all that i could as a staff RN to follow doctors orders?

what do you think?!

[RNewbie]

I try not to document in a way that seems to throw another nurse under the bus, but I do chart to cover my behind. I have never encountered a situation in which a 1:1 was disregarded in this way. How do you just pull the tech on a SI pt? If it were me and I only had one pt I would sit with the pt to free up the tech to help out on the floor. From the info you provided I would have charted in a similar manner and contacted the supervisor about the issue. You do not have control over the staffing. The supervisor and charge are responsible for that but you should advocate for your pt. The charge nurse could have also sat in the room with the pt if that was an option. It seems like this entire situation was taken too lightly. If this pt ended up harming himself it would have been bad for all involved. Your co workers are always going to have an opinion but I always reference the policies and procedures when trying to get my point across, just print it off and show them. It's sometimes hard to go against the grain when everybody is saying that it's not a big deal, that you can see the pt from the nurses station, that you are making a big deal out of nothing, and they need the tech on the floor. If something were to happen to that pt, they would be the main ones saying that there was an order that should have been followed, they would have called the supervisor, and they would have followed the policy. You did the right thing.

[BostonTerrierLover, BSN, RN]

In a large hospital in the DFW area, I saw a hospital with a 1:1 suicide precaution policy try to put a Tech in room watching 2 patients. She refused, but was literally "went off on" by a nursing supervisor who ultimately sent her home for insubordination. A complaint was filed by the Tech who ended up getting paid for the shift while the Supervisor resigned during her suspension. Most Hospital Administrators take this policy very seriously- and failing to meet the standards of the policy even more serious. I have seen them put MD residents on 1:1's in low staffing situations.

[anotherone, BSN, RN]

Charge nurse aware? That won't go too far. i would call the nursing supervisor.You don't have to be in charge to do that. Most would pull a tech from another floor if it came down to that. I have seen this done where I work many times. This is one of the times were pt to staff ratios are actually followed.

[anotherone, BSN, RN]

. I have seen them put MD residents on 1:1's in low staffing situations.

And I thought our staffing was bad!!!!!! Do they take call from the pt's room? I am being serious. I don't know how this would work in my hospital on night shift.

[BostonTerrierLover, BSN, RN]

And I thought our staffing was bad!!!!!! Do they take call from the pt's room? I am being serious. I don't know how this would work in my hospital on night shift.

No, it's an emergency department I failed to say, so they are pulled off from taking cases, and placed on the 1:1. It's rare, but with the holidays coming, it will happen. There are always plenty of interns and residents in this Med Ctr's ED, they get great educations, but they also get to do full care, lol.

But, in my opinion, they come out much better rounded physicians who can start IVs, foleys, stoma care, and so on. I have rarely done their dressings, they do "full care" on their cases. So, if your the resident MD or Intern who unfortunately picked up the case, 1:1, while the others make fun and head for their sleep room.

[Anna Flaxis, BSN, RN]

This might seem like splitting hairs, but I never chart that someone else is "aware". You can't really say for certainty what anyone is aware of. I chart "Charge Nurse notified" or "MD informed" or something to that nature, which describes an *action*, not an assumption about someone else's state of mind.

It's similar with patient teaching. I never chart "Patient understands". Instead, I always chart something like "Patient verbalizes understanding and gives appropriate return demonstration".

[hiddencatRN, BSN, RN]

I agree that "charge RN made aware" doesn't cya, but it does mean that if something happens, they will have to answer in addition to the primary RN. It's not throwing them under the bus; it's pulling them under with you. If the charge RN doesn't like that, the charge RN should have prioritized that 1:1.

[~Mi Vida Loca~RN, ASN, RN]

We have security watch our Suicidal Patients, not our techs or Nurses.

[Tiffanybaybay]

OK, I'm actually glad I posted this for future reference. It was a slow night and I was able to watch him all night. I didn't get any other patients. But I did sit at the nurses station and I didn't sit within arms length like the policy stated. I didn't think of sitting in the room to maintain the 1:1 myself because another patient could have arrived. Now that you guys have made it clear it seems like the most appropriate thing would be to be the 1:1 myself and become unavailable if another patient would arrive.

I think that would put the burden on the other nurses you know? Sitting in a room while another patient arrives. Nothing happened and he was fine but I needed to know how to handle this situation because it has happened, and things went wrong. I've seen nurses step away from a patient only to return and find the patient hanging by his belt from the ceiling. I don't want that to be me.

Also it is interesting to note that charting that the charge is aware wouldn't CYA. I guess I've always felt that if they were my superior they are responsible for the decisions they make, since they have the ability to make them and I don't. But I guess that if I know better then I need to stick up for myself. I always second guess myself, so I guess that's where the passive aggressiveness comes in. There's a voice in the back of my head saying, no you're wrong, they know something more than you. I guess I have to learn to become more confident. THANKS!

[CountyRat]

I agree that "charge RN made aware" doesn't cya, but it does mean that if something happens, they will have to answer in addition to the primary RN. It's not throwing them under the bus; it's pulling them under with you.

Another way for describing this is, "getting into the same lifeboat as the boss." I hope the ship does not sink, but if it does, I want to be in the boat with someone with more to loose, and more power to survive, the consequences.

[Esme12, ASN, BSN, RN]

OK, I'm actually glad I posted this for future reference. It was a slow night and I was able to watch him all night. I didn't get any other patients. But I did sit at the nurses station and I didn't sit within arms length like the policy stated. I didn't think of sitting in the room to maintain the 1:1 myself because another patient could have arrived. Now that you guys have made it clear it seems like the most appropriate thing would be to be the 1:1 myself and become unavailable if another patient would arrive.

I think that would put the burden on the other nurses you know? Sitting in a room while another patient arrives. Nothing happened and he was fine but I needed to know how to handle this situation because it has happened, and things went wrong. I've seen nurses step away from a patient only to return and find the patient hanging by his belt from the ceiling. I don't want that to be me.

Also it is interesting to note that charting that the charge is aware wouldn't CYA. I guess I've always felt that if they were my superior they are responsible for the decisions they make, since they have the ability to make them and I don't. But I guess that if I know better then I need to stick up for myself. I always second guess myself, so I guess that's where the passive aggressiveness comes in. There's a voice in the back of my head saying, no you're wrong, they know something more than you. I guess I have to learn to become more confident. THANKS!

We live in a litigious society. Saying the charge nurse aware....doesn't say they were notified. If the charge nurse wants you to help the other nurses they would use the resources more appropriately. I would encourage you to notify the supervisor as she sent the help for a specific reason and not for the charge nurse to "pull them" as soon as they arrive......and use them as they saw fit. The supervisor was pulling them for liability to provide them with 1:1 "arms length" observation. I would take the charge nurse aside and remind them what the tech was sent for and if they could not utilize them as untended I would return them to the floor the I pulled from.

If another patient arrived....then the charge nurse has one of two options. Re-direct staff to best utilize the staff available....OR.....take the patient that arrived. Their choice. You need to care for you.. Politely.......but care for you none the less. Always post this stuff....get the public opinion. In a court of law the "reasonable and prudent" thing to do and nurse is the "standard" of care. Inform yourself......education/knowledge is power. I've seen patient remove needles and heroin form some very unusual places and shoot up and over dose. A SI patient with a plan....will carry out that plan and the next opportunity. Some patients are well versed in the system....contract for safety and I had one one that psych discharged (against all protest by me) and hung himself in the parking garage. Trust me that didn't get on the news.

While we are on the subject....get malpractice insurance.....“Praemonitus praemunitus” translates to “forewarned is forearmed,”

I wish you the best!

[Metody]

Just because a patient is calm doesn't mean they've stopped being suicidal. Sometimes it means they've finally figured out how to do it, and all their worries are going to be lifted. It's very soothing to think that soon, you won't be in any more pain. And just because they appear to be still, that doesn't mean they're safe, either; in nursing school, when we did our rotation in the psych ward, one of the patients had massive scarring on his forearm from when he'd found a paperclip and carved at himself. He'd been in bed with his back to the door and was quiet and discrete enough that no one found him until he'd nearly hit bone.

Your charge nurse is dangerous. She knew she was doing the wrong thing, and she was ****** because now there's a record of it.

And to address the issue of throwing burden on other nurses: that wouldn't be your fault. It'd be the fault of whoever decided it was more important to have an aide on the floor instead of another nurse.