Time Consuming Facility - Suggestions?

[Race Mom, ASN, RN]

Background: 2 facilities owned by same company. I'm am their preferred hospice nurse. I communicate very well with them and that is why they prefer me (their words).

One of the locations is very easy going, allows mini crisis kit, will allow verbal orders until signed one is faxed, will allow single syringe doses of morphine/Haldol/etc. and enough so the pt won't run out over a weekend.

The other one...another story. The admin will not allow crisis kit. Ok. We can manage that. But, this admin is starting to put me into overtime on hospice payroll.

PRN O2 can not have a range. Fine. They won't accept the O2 DME until they have a signed order. Fine (pt will just have to wait). Once they get the order I have to keep asking them to help the pt with using it. (education moments, fine...but continual)

They are staffed by med techs and at night it is just one. I have had to go oncall to help them find THEIR meds in THEIR med cart (found). Fentanyl patch over bony area on back (teaching again to the med tech)

Today...PRN visit for decline. Most of his "declines" are d/t not having his hearing aids working and he doesn't respond so they call us that he is at EOL. (teaching)

3 falls in one week doing the same exact thing...getting up from the dining table. I finally had to tell them that they immediately have to give hands on for all transfers.

They wheeled him into his room and left him in his wc. Near fall when he tried to get himself out.

Increase pain. During phone call before visit, asked them to give ibuprofen (inflammation pain) and follow up with pain pill, check placement and age of fentanyl. I arrived about an hour later. Ibuprofen given, no pain pill, no fentanyl check. I checked the patch and it was stuck to his shirt and he had had incontinence episode (soaked bed) which may have gotten on the patch. I educated to monitor pain level for next hour and if no improvement, to change the patch as it may not be effectively medicating. I got an "ok"

Today, he's having a hard time talking (hearing aid not working). Changed batteries. Gave pain meds. Moistened lips and got a "thumbs up". Informed admin that they need to replace that patch (due to be changed next day). She says "we need an order for that". I asked why they would need an order if the patch was compromised and she said d/t order Q 3 days and anything else needs an order. He also would like to have his O2 when he goes into the dining room. I told staff that I would have some portable tanks delivered. They said "we need an order for that". An order so he can wear oxygen when he crosses a line in the carpet???? (didn't say that, hahah). Then told me that they think he is ready for morphine. "Anything we can do to give him comfort". Um, I can think of a lot of things that they aren't doing that I continually request they do, but if we can switch to morphine and they will GIVE IT, then I will! But...they will only accept 20 single dose syringes. No more. Because.......... "20 is easy to count". I told them that I would check on them every Friday to make sure he had 20 for the weekend but there is the chance that he could run out. They refuse to allow more at one time. (ugh...his comfort huh?)

So, I rush back to the office with my new order typed, printed, given to the office mgr who drives it to the Dr. office for signature, drives it back to me and I fax it to them and the pharmacy, I call facility to tell them the orders are signed and to pull them up on their electronic fax and to expect oxygen, meds, and to change that patch asap "ok", call DME to deliver order for "oxygen tanks for wc". DME calls facility to get info for delivery and they said "we don't have an order for oxygen". (ugh)

Can't get ahold of facility. 20 minutes later, get a call from our on call nurse saying the facility called and needs orders for this stuff.

Boy...all in all...over 5 hours spent between visit/travel/calls/education/charting today.

This facility is beautiful and the other location is so well run and fun but I don't get it. What would you do? How can I make my visits more efficient and provide all this education to their staff about meds/falls/etc but not get home at 9pm?

This is a private pay ALF.

[duskyjewel]

Since you're on good terms with the ownership, go talk to them about it. They can't be aware of your difficulty if you don't tell them about it, and they hire people to run these places so they don't have to keep track of everything themselves. They may actually not be aware of how this admin is running their facility. Perhaps your difficulties, when reported, will give them a chance to find out they have an employee they don't want anymore, or will provide an opportunity for education and correction for an employee who may be struggling. Since you have the rapport with the owners, use it to advantage for yourself, your patients, and for them.

[Race Mom, ASN, RN]

Thanks duskyjewel, it is the admins that like me being the RNCM. I'm not in touch with the owners at all. I would fear our hospice would be banned if I complained, questioned. You were thinking what I was though, that I should ask higher up, but I don't know. I feel that would make the situation worse. This admin has her CNA and that is as high up as her medical education goes. She was (IMHO) bullying me today by "suggesting" morphine so "this pt can have some comfort". I bit my tongue since that is what I've been advocating and educating towards. One med, that he desperately needs for congestion that makes him have N/V, she admitted that if "you want it to be given you should order it scheduled, it's the only way to make sure it is given". I did just that, but if he is gagging and puking from thick mucous...can he PLEASE have his mucinex???? Now I'm wondering how to get him transferred to the other facility of theirs that DOES know how to give PRNs.

[vintagemother, BSN, CNA, LVN, RN]

"One of the locations is very easy going, allows mini crisis kit, will allow verbal orders until signed one is faxed, will allow single syringe doses of morphine/Haldol/etc. and enough so the pt won't run out over a weekend."

****whats their rationale for not allowing a crisis kit? I've had these in both the non medical ALF I worked in and the Non medical psych facility.

****I do recall that in the ALF the nurse mgrs and admin actively counseled families of hospice residents to refuse to give PRN pain meds, though.

****At the ALF, We were taught no verbal orders are allowed due to community care licensing regs.....even though they recently began using nurses instead of med aides.

****At my current non medical LTC we take verbal orders all of the time.

****This makes me wonder if my former executive director was lying about the regs or just misinformed.

****Every question we had about doing things the way that made sense or the way if been taught prior was net with the answer, "we're regulated by community care licensing and are non medical, so our regs are different

"PRN O2 can not have a range."

****we were told by non-nurse executive director that we can't have any orders with ranges. But then the RN on staff said we can but we can only administer the lower end of the range.

"Fine. They won't accept the O2 DME until they have a signed order...Once they get the order I have to keep asking them to help the pt with it"

****speaks to the real issues going on at the facility

"Most of his "declines" are d/t not having his hearing aids working and he doesn't respond"

****i had to constantly request that the hearing aids were placed in residents ears when I came on shift at 3pm

"Informed admin that they need to replace that patch (due to be changed next day). She says "we need an order for that". I asked why they would need an order if the patch was compromised and she said d/t order Q 3 days and anything else needs an order. "

****again, makes we wonder if this is really the "rule" at ALFs or an excuse.

"He also would like to have his O2 when he goes into the dining room. I told staff that I would have some portable tanks delivered. They said "we need an order for that". An order so he can wear oxygen when he crosses a line in the carpet???? (didn't say that, hahah). "

****i feel the same way you do about this (-;

"What would you do?"

*****i wish I had answers. As a new grad, I don't know enough about the real rules of non medical facilities to be of assistance. But, having worked in an ALF and having had a bad experience, I am very interested in reading replies from experienced nurses.

****The bottom line, at the one I worked in, was that everything that was going on that made no sense to me was excused and encouraged by the non nurse director under the explanation of "we're not medical". As a new grad, I didn't know enough to refute any of it.

about meds/falls/etc but not get home at 9pm?

This is a private pay ALF.