Untrustworthy supervisor

[Kaysmom8]

Did anyone ever have a supervisor that was 100% well known to be very very untrustworthy? Tonight I had a patient with a very low bp and I called MD who said send him out and the supervisor wanted to speak to the MD before I hung up. Before I know it she comes to tell me that the MD changed his mind because the supervisor said she felt comfortable with keeping the patient. Mind you she did not take responsibility for the patient and left him in my care and put a order in for midodrine to raise his bp. Well we didn't have that med available and she tells me oh don't mark off not given just go discontinue the order. Now by this time I'm extremely suspicious why would I carelessly chart not given or go as far as simply discontinuing her order... Get this she even "did me a favor" and charted that she spoke to MD and told me don't worry you don't need to chart a thing. I go look at her note and she lied about the Bp and pulse. So frustrated with this supervisor.

[madwife2002, BSN, RN]

Morning I have moved your thread to Nurse colleague relationships

[TheCommuter, BSN, RN]

So frustrated with this supervisor.

Your dishonest, boldfaced liar supervisor is probably frustrated with you, too, but for different reasons.

I assume you work in a SNF, nursing home or assisted living. Your supervisor is probably under intense pressure from upper management to avoid sending patients out because:

1. Send-outs reduce census, thereby reducing cash flow

2. Ambulance transports are ridiculously expensive

3. It is more cost-effective to treat patients in-house

I am not condoning the behavior of your supervisor who lies through her teeth, but a low BP is often something that can be treated in-house. The other night I had a patient with a BP of 60/42. After placing her in Trendelenberg position and administering a bolus of fluids, the BP rose to 100/58. Low BP can also be treated with medications.

I agree that your supervisor is a liar. However, I can appreciate her viewpoint up to a certain extent. Cost containment is the wave of the future in post-acute care, especially in the face of dwindling Medicare and Medicaid reimbursement rates.

Therefore, those of us who work in these settings are going to need to stop panicking with every change in condition and start utilizing our nursing skills to address the problem before it turns into a "Send them out!"

[Esme12, ASN, BSN, RN]

I don't know the patients history but if the MD rdered a drug and you don't have it you need to call the MD back and just not pretend that it's all ok and go "discontinue" the order...you call the MD whether she likes it or not. I agree that these decisions are made based on losing costs with send outs...however...if this was my family I would be LIVID if my family was a failure ot delay to treat....which buy the way is one of the most common lawsuits filed...and won.

If this would go to court you would be liable for "knowing better" to call the MD.

In all cases cover thine own behind! Be sure you have malpractice insurance and I know that you are looking for another job...get out of there.

[TheCommuter, BSN, RN]

I don't know the patients history but if the MD rdered a drug and you don't have it you need to call the MD back and just not pretend that it's all ok and go "discontinue" the order...you call the MD whether she likes it or not.

Again, I assume this is a post-acute setting such as LTC, SNF, assisted living or group home. If so, these types of facilities are usually contracted with one or more remote pharmacies who will deliver medications STAT if something is currently unavailable.

So if the midodrine was unavailable, the nurse or supervisor could have telephoned the remote pharmacy and arranged for the the medication to be delivered STAT. Also, many local hospitals with 24-hour pharmacy staff are more than willing to allow local nursing homes to borrow medications.

But, wait a moment. STAT medication deliveries cost money. Borrowing medication from the local hospital also costs money, and it appears as if the liar pants-on-fire supervisor has been appointed to be the unofficial dollar counter during the off-peak hours.

[CrunchRN, ADN, RN]

Wow. Puts you in a very tough place. Call the doc and do what he says or tell her to care for the patient because you do have to follow orders....

[Esme12, ASN, BSN, RN]

Again, I assume this is a post-acute setting such as LTC, SNF, assisted living or group home. If so, these types of facilities are usually contracted with one or more remote pharmacies who will deliver medications STAT if something is currently unavailable.

So if the midodrine was unavailable, the nurse or supervisor could have telephoned the remote pharmacy and arranged for the the medication to be delivered STAT. Also, many local hospitals with 24-hour pharmacy staff are more than willing to allow local nursing homes to borrow medications.

But, wait a moment. STAT medication deliveries cost money. Borrowing medication from the local hospital also costs money, and it appears as if the liar pants-on-fire supervisor has been appointed to be the unofficial dollar counter during the off-peak hours.

I agree and I have heard those conversations...but if the med was unavailable the MD still should have been notified to then make the decision to order another med or transfer out the patient. To the supervisor to just say

oh don't mark off not given just go discontinue the order.

is not okay...it just isn't and if that family sued saying the patient died or stroked from low B/P the facility the supervisor AND the nurse would be culpable for their actions.

I ran into this once or twice as the supervisor. One at a critical access the patient had porphryia and one at an LTAC I can't remember but it was an antibiotic I believe....I got the med delivered. One facility paid for the taxi delivery (LTACH) one I paid for the taxi (critical access).

I get the whole cost containment thing but I just can't in all good conscience participate. I quit both jobs.

[dudette10, MSN, RN]

You've got three problems...a supervisor who lies about patient care, a low BP left untreated, and no one attempting to find out what caused the low BP to fix the actual problem (the low BP was just a symptom).

After my my experience with my MIL (who went from "let's just throw some oxygen on her" to in the ICU with sepsis and died five days later from flu A), I would argue that an LTC nurses assessment and critical thinking skills need to be BETTER than an acute care nurse's skills due to the lack of resources and fewer eyes on the patient.

Was the problem ever identified and addressed, or did it just end with no treatment? You mention that the supervisor lied about the BP and pulse rate. Was the HR high? Was it regular or irregular? Could the patient be dehydrated?

[Kaysmom8]

I called to have the unavailable med delivered. I did manage to get him sent out and turns out he had a GI bleed.

[Tenebrae, BSN, RN]

At the end of the day you need to do what you have to do to protect your registration.

Were something to go wrong, its quite possible she will deny that she ever said anything....

I had a situation Y day, patients fentanyl patch was increased and the doc didnt stop the old patch. This ladies dose went from 50mcg to 125mcg. Was supposed to be 75mg total. The nurse I was on with told me that it wasnt an incident, and I didnt need to file a report. Now, I can understand that none of us really wants to document someone elses mistake, especially when the Drs charting was unclear, however in essence the patient ended up being overdosed with an opioid pain reliever

I did the incident form.

[jadelpn, LPN, EMT-B]

A low blood pressure in itself is something to be assessed--is the patient on HTN medications that need to be held/adjusted/etc? What else was going on with the patient? If the patient had a GI bleed, black, tarry stool would also be an indicator.

After a complete assessment, THEN I would call the MD with all the symptoms. If the supervisor gets involved, again, the supervisor needs to know the full story, as opposed to "just" a low BP.

Yes, it was absolutely wrong of the supervisor to lie, chart things that are not actually true, and the like. The supervisor charting that she was the one who spoke to the MD and the decision was made not to send out is on her.

With all that being said, if a low BP is happening, there's got to be a reason. And to do a complete assessment to give the MD and the supervisor a full picture covers you. "Patient has BP of 80/50, and black, tarry stool. Supervisor Xyz, RN notified. MD notified. Orders to ___________________."

Get malpractice insurance with practices such as this where you could be smack in the middle of a sticky situation, Going forward, just make sure you have the full assessment, then call. Even if the MD decides to treat with meds, you could advocate for a general lab draw to attempt to locate the issue that needs treatment.

[icuRNmaggie, BSN, RN]

What happened with that patient is a huge red flag that you should not ignore.

You do not want to be affiliated with people who can not behave in an honest and ethical manner.

I would mention what happened to the physician; he or she has a right to know that this patient's care was compromised by an unethical supervisor.

That supervisor who refused obtain medical attention for an unstable patient will throw you under the bus in a minute.

These types are extremely vindictive when their dishonesty is exposed. Get out now.