Who would you take a verbal order from?

[longhornfan1]

Just curious. Work as LTC Weekend Supervisor. Have LVN who works the floor, but also takes call for a physician who has several patients in the facility. The LVN scope of practice prohibits independent nursing judgment and limits them to focus assessments. There by limiting their ability to evaluate an acute change in condition, take action to repair the condition by executing orders for medication, labs or tests without directly consulting the APN, PA or MD. So, when the MD is called, the service directs me to the LVN standing next to me. (Yes, she is taking call while she is working the floor!! Huge conflict). Then she actually gives me an order, based on her interpretation of labs or other vital signs, for additional labs, x-rays to confirm her suspected diagnosis, antiemetics, antipyretics, PPI's etc. All without checking a chart for possible drug interactions (like she would recognize one) or allergies to medications!!. The DON and ADM are fully aware of this "Practice of medicine" and I am curious, should I notify the BON, on both LVN and DON, the Dept of Age/Dis to intervene for potential immediate harm to a patient, and the Board of Med for delegation violations on the MD's part? I know I hold responsibility for direct report for practice violations on the LVN's part at least to cover my license as a mandated reporter!! Just curious. Have my NPA, Occ Codes and all the necessary doc's to move forward, just don't want to destroy any careers. But, she is obviously in over her head, but orders with complete disregard to patient safety. Thanks

:angryfire

[Tweety, BSN, RN]

This is wrong on so many levels. I would use the chain of command before going to the BON, but it sounds like they are aware. (LPNs certainly can recognize drug interactions as they pass meds frequently).

I take a lot of phone orders in my day as a charge nurse, but only from ARNP's, PA-C's and MD's. Only persons licensed to give orders should actually be the ones giving them.

[longhornfan1]

We just had the stomach flu here and sent out patients and staff to the hospital. She was standing there all day, barking out orders for phenergan and immodium like it was candy!! Isn't there a procedure for on call nurses. My husbands uncle is an MD here and I am curious as to his POV

[longhornfan1]

Major other issues re: false doc. She had documented on all 20 of her Medicare patients, just 15 minutes after getting report. That is on my report to the BON also. Think a "cease and d" order is a good idea here!!!??

[Rexie68]

then she actually gives me an order, based on her interpretation of labs or other vital signs, for additional labs, x-rays to confirm her suspected diagnosis, antiemetics, antipyretics, ppi's etc. all without checking a chart for possible drug interactions (like she would recognize one) or allergies to medications!!.

:angryfire

while i certainly agree that the lpn/lvn shouldn't be giving orders for the md, it sounds like you have a problem with lpns in general. an rn shouldn't be giving those orders either.........unless she has an advanced degree and is in practice with an md/:angryfiredo who backs her up.

[TheCommuter, BSN, RN]

All without checking a chart for possible drug interactions (like she would recognize one) or allergies to medications!!

I'm an LVN, and I can definitely recognize possible drug interactions. It seems as if you already have your mind made up regarding the course of action that you plan to follow, so I am not going to bestow any advice upon you. You've already made the decision to report this nurse to the TX BNE.

Now, back to your original question at hand. Who would I take a verbal order from? I'd take a verbal order only from an MD, DO, PA-C, DDS, or any advance practice nurse such as an FNP.

[Blee O'Myacin, BSN, RN]

Just curious. Work as LTC Weekend Supervisor. Have LVN who works the floor, but also takes call for a physician who has several patients in the facility. The LVN scope of practice prohibits independent nursing judgment and limits them to focus assessments. There by limiting their ability to evaluate an acute change in condition, take action to repair the condition by executing orders for medication, labs or tests without directly consulting the APN, PA or MD. So, when the MD is called, the service directs me to the LVN standing next to me. (Yes, she is taking call while she is working the floor!! Huge conflict). Then she actually gives me an order, based on her interpretation of labs or other vital signs, for additional labs, x-rays to confirm her suspected diagnosis, antiemetics, antipyretics, PPI's etc. All without checking a chart for possible drug interactions (like she would recognize one) or allergies to medications!!. The DON and ADM are fully aware of this "Practice of medicine" and I am curious, should I notify the BON, on both LVN and DON, the Dept of Age/Dis to intervene for potential immediate harm to a patient, and the Board of Med for delegation violations on the MD's part? I know I hold responsibility for direct report for practice violations on the LVN's part at least to cover my license as a mandated reporter!! Just curious. Have my NPA, Occ Codes and all the necessary doc's to move forward, just don't want to destroy any careers. But, she is obviously in over her head, but orders with complete disregard to patient safety. Thanks

:angryfire

So I'm curious. Have the DON and ADON come out and said "take verbal orders from this LPN"? Or were they turning the other way when it was happening? Because if there is no hard evidence that the facility was playing a part in any illegal activities, both the ordering nurse and the nurse accepting the orders are culpable. Why hasn't anyone (like you, perhaps) asked her why she's practicing medicine without a license? Has anyone refused to take a verbal or telephone order from her and documented as such? Or are the orders written up as "v.o. from Dr. XXX...." when it was clearly not given by Dr. XXX? If so, there are many people accountable here, and not just this one nurse who is giving the orders. And I'd think that the medical board needs to know as well - they have their own disciplinary system.

This is a big can of worms you are about to open - and I'm not in any way suggesting that you stay silent. However, know that anyone who knowingly took an order from a person practicing medicine without a license is just as in violation of BON regulations, yourself included.

Good luck. This isn't an easy place to be.

Blee

[longhornfan1]

Thanks for the support. I have researched the NPA, Medical Board, Administrative responsibilities, and the DON and ADON made me aware of her "on call duties" when I was hired. Initially, she would say "Ok, let me call the Dr." I had asked her once, as the on call nurse, if I could get a verbal to DC a MVI d/t pt refusal for 60 days, she said, "You have to call the dietitian for that order" SNOB, but recently she has been using her own judgment. I spoke w/my Uncle (MD) and he is very familiar with the MD in question. We actually had my g-ma at this facility about a year ago, and I was told that this same nurse, DON, and Adm. were informed by my Uncle that they were walking a very thin line and he even gave a courtesy call to the MD prior to his report to his Med Board. So, I guess maybe since he is the Medical Director for the facility, and the facility is independently owned, they believe they may be above reproach. However, the state still mandates the rules for care, licensure, facility requirements and best of all...FUNDING for the facility. As for my actually accepting an order from this nurse on behalf of the MD, never happened directly to me, however, as the Nursing Supervisor, she was operating under my direct supervision while performing (concurrently) her on call duties. So, I still take responsibility for the delay in reporting, but will submit a written report as well as a verbal request for C&D on her LVN license just before I hand copies to the DON, ADON and ADM. PS. I have been an LVN for 5 years and made my priority patienty safety. Know my NPA front and back. Have been an RN for 7 months and am REQUIRED to know the R & R for my Med Aides, CNA's and LVN's as I am ultimately responsible for ensuring minimum standards of care and adherence to their practice limitations too.

So, here goes nothing. Will post an update, if I am not imprisoned too!.

[longhornfan1]

The question of medication interactions and the LVN's inability to recognize such was not meant as a "Bash" to all the diligent and self-educating LVN's currently practice safe nursing care. Sooooo sorry to have made this implication!!!. PS. Still have my active LVN license and proud of it!!.

We are each professionals in our respective areas should we choose to excel!

[SuesquatchRN, BSN, RN]

I think being an RN has gone to your head.

I would be ordering phenergan and immodium for stomach flu all over the place, too, from standing orders, which any LTC has.

[Patti 2nd gen RN]

It didn't sound like there were standing orders in this situation...That is a different situation....at my facility--we have 'hospice' patients, and the hospice nurse will come, eval, talk to her doc and call back with orders--but unless that doc has practice privileges and faxes us the orders, we don't take the order from the nurse, we callour doc, review the suggestions, and go from there....

[morte, LPN, LVN]

I think being an RN has gone to your head.

I would be ordering phenergan and immodium for stomach flu all over the place, too, from standing orders, which any LTC has.

LTC places that i have worked do NOT have standing orders for such things

AND

we are not to take verbal orders from any one, per JACHO, if the person is present they are to write their own orders....