What to do, what to do.

roma4204, BSN, RN · May 17, 2011

I don't have any LTC experience but it seems this would be a really simple fix on the part of your DON. A policy should be made regarding delay of care...I mean my god - that is ridiculous! If I see an order for a med that is new...I assume it means start it ASAP unless it is written for another time.

GooeyRN, ADN, BSN, CNA, LPN, RN · May 17, 2011

A simple memo sent around from the DON could address this issue. We had this issue on med/surg with swing bed patients. Everyone wanted new orders on someone elses shift. No one wanted the routine meds on their shift. So a memo was sent around saying all meds were given at certain times. None on nights other than stat, nebs, abx recently ordered, or those required without food could be given at 0600. It was clear no meds should be given between midnight and 6am, unless a stat order or prn. Once a day meds were to be given on days in the am, period. Other than certain things like coumadin, etc. that are routinely given in the evening. Once a day abx were to be given on whatever shift they were ordered. If it happened to be between 0000 and 0600, the next dose would be transferred to the morning dayshift med pass. It cut out a lot of multivitamin orders for 0600 and baby asprin orders for 0000 type stuff. It was to be a more rare thing for meds other than prn to be given at 0600, 0000, or anywhere inbetween.

Mrs. SnowStormRN, RN · May 17, 2011

When I worked LTC I worked evenings and days and I must says days were crazy. Usually we had to put some meds at 6am (like a patch) because 9am most people were taking like 20meds or so. The MD never seemed to take the patients off of old meds only added new ones. I think some meds can be put on other shifts, especially because some meds like Coumadin should be given in the evening. When I worked the other shifts I had waaaay more down time (in my facility). The days we usually had all the QD, BID, TID, and QID meds plus majority of the treatments, appointments to send patients too, meetings to attend during our shift, usually the dr comes in during the day with a ton of more med orders, PT, OT, ST were always down our backs during the day - maybe she is comparing the workload of the shift. If its a med that can be given during a slower shift, why not? We are a team. I say work days for awhile. I use to only put before breakfast meds at 6am because in LTC it was hard to get meds to people before breakfast after report. Patches on a different shift I did those on the evenings all the time (not every patient though, it was an even amount split up, some patients had them changed in the day, some had them changed before bed). No big deal. I say ask if you guys can have a mandatory staff meeting so you can see the day nurses point of view. LTC is difficult on any shift but days were more hectic in my opinion, I dont see how a lazy nurse could survive days. I use to work skilled care which was outrageous during the day and in the evenings I had so much more time to do things. IDK, because I dont work at your facility but we had an issue like this where I worked. The evening shift did a shift swap and needless to say, it was a great way for the nurses to see the others point of view. When youre looking on the outside in, its easy to assume that the nurse is just lazy - but they may not be the issue. See if you can see whats going on? Are there med interactions? Is the dr refusing to dc old meds? Are they meds that should only be given in the am? Are they meds that should be given at 6pm like Coumadin? I say call a meeting with day shift and see if you can say your issues and dayshift can express theirs. Good Luck to You!

merlee · May 17, 2011

New orders should be started at the nearest appropriate time, and adjusted accordingly. If a patient needs antibiotics, and the med is not given as soon as available, this is a delay in treatment and needs to addressed as such.

I don't know your pharmacy situation, but if the meds arrive before the shift is over, then they (esp. ATBs and such) need to be given right away.

And I wholeheartedly agree with no meds between 10 pm and 6 am, or HS and 6 am unless there is absolutely no choice. And the only early AM meds should be those that MUST be taken on an empty stomach at least 1 hour before meals.

As a person who takes a 'whole bunch o'meds' in the morning, I prefer mine during breakfast!

fanfan8787RN · May 17, 2011

The bottom line is if the DON doesn't feel the need to address the issue, then nothing will be done. Complaining about the situation may have negative consequences for you. Good luck.

morte, LPN, LVN · May 17, 2011

1) Being busy is now excuse for allowing a patient to wait for a med.

2) Three-eleven should check charts and call docs to get the orders changed.

3) Check your P+P, it may cover this issue, and you can tell miss slug to "look it up" after you change it to appropriate times.

needtoknowbasis · May 17, 2011

Facility protocol requires that unless otherwise stated: QD = 9a; BID = 9a, 6p; TID = 9a, 1p, 6p unless Q12 hours which means it's at 9a and 9p unless otherwise ordered; QID = 9a, 1p, 6p, 9p unless otherwise stated such as Q6 hours which would then be 12a, 6a, 12p, 6p.

I used to only work day shift and evening shift and had only switched to night shift the past few years because I attend college classes in the morning. If it's really that big a stupid deal, put everything at 6a or on 11-7 because I will do it. I will do it with a huge smile on my face and not say a word if that's what the doctor and resident/resident's family wants. Don't do it just because you want to mosey around and ignore call lights, not have to worry about doing any treatments since there is a treatment nurse there every day of the week, or worry about actually calling the doctors because you have a unit manager who does it all for you.

Is this really that unreasonable? How is her hall, one of six mind you, in the facility so special that this gets to go on and on while everyone else follows facility policy and protocol?

needtoknowbasis · May 17, 2011

Trust me, this site/forum isn't the first place I went to with this problem. I went to her first, then the unit manager, then the DON, and pretty soon I believe I will be hitting up the Risk Manager at my facility about this. What kind of shady nurse writes orders without consulting the doctor to change times to make it more convenient for them? This happens nowhere else in this facility.

Edited to add: Antibiotics are very easy to come by at my facility because our EDK has an extensive list of what we can take out if the doctor orders it. We are supposed to give the first dose from the EDK, notify our pharmacy, and then it should be delivered promptly for the remaining doses. This really isn't that difficult, why does she have to make it so hard on everyone else?

mazy · May 17, 2011

I have encountered similar problems where I work, not because people are trying to get out of passing new meds as seems to be the case in your facility, but because there is sometimes confusion about med times.

What I, and other nurses do is write a T.O. stating "clarification of order, per pharmacy protocol med time changed to X:00/set for X:00." To make it stick, you can leave a message with the MD, or talk to the MD in person and address the T.O to Dr. So and So.

Don't know if that would solve your problem but it creates a paper trail that is hard to ignore.

bythebookRN · May 17, 2011

In my state (Indiana), I believe there is a law that antibiotics have to be started within 2 hours of being ordered. If it is not a law then it is our facility policy and is strictly enforced. Most antibiotics are in the EDK. Your facility policies and procedures should be of help to you.

needtoknowbasis · May 18, 2011

I already know my facility's policies and procedures. I've shown her specifically where it says that exact thing and yet it still is ignored.