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Discussion

Written Guidelines for HH nurses?

I am having difficulties finding written guidelines in Homehealth nursing, specifically. Generally, most education/ training is given for a hospital position. I am working in pediatrics and have had 2 cases in a row that due to the parent's refusal to call a doctor when the nurses deemed it neccessary or withheld medication (or allow the nurses to administer,) that a doctor has prescribed for the child, there is an increase in risk for injury or danger to these children not to mention liability to the nurse. The medication is not even available for the nurses to give.

I have an immediate supervisor who said I should go over the parent's head and call the doctor myself, and another supervisor who said I can't go over the parent's head, that the parent has the right to refuse medication and or treatment.

The nurses on the case have been told by one supervisor to LEAVE THE MAR BLANK... (if you can believe that,) not to write on the mar that the parents refuse the medication administration by the nurse.

(I'm thinking that would put the parents in a possible AMA situation where their nursing services may be jeopardized, thus a lost case for the agency?)

How do the nurses protect themselves? Where are our guidelines? When your agency doesn't seem to support it's nurses...

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    • Expert

    I have only ever encountered one Director of Clinical Services who has backed up her nurses and insisted we do things according to prudent nursing practice. All others have preached, "Do what the family wants, do what they tell you to do, blah, blah, blah, kiss their backside, blah, blah, blah." I would not call the doctor to establish a confrontation with the family, but to inform the doctor what is going on. The doctor needs to know, no matter what the parents are doing or not doing. Leaving the MAR blank is a big fat NO! If the med is scheduled for 1400 and the parent won't let you administer it, you document that the med was withheld per PCG request. If the parent insists on giving the med and you observe them giving it, then write in "PCG". No way would I leave a blank hole for a med that was due on my shift. That is courting disaster. When they are noncompliant, I document it. I document it in my shift notes. I quote the parent. I write up individual and summary communication notes and send them forward, addressed to the nursing supervisor and/or the doctor. I call the doctor if appropriate. I do this every shift it occurs. When it comes time for the lawsuit, I make sure there are plenty of pieces of paper with my signature on them that tell the story and describe clearly who is calling the shots. And I make sure my malpractice insurance policy payment is up to date.

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    • Author

    First, I want to thank you for being here to help other nurses...I don't know who you are, or what your qualifications are, but it's very nice of you to take this time to help other nurses. Many nurses seem so cutthroat...an odd characteristic considering the profession.

    I have been on this case for 1 1/2 weeks. I only work part time. The full time nurse has informed me that she has tried to convince the mom to give the medicine to the baby, but to no avail. I must say, that I just went along with this other nurse (but not the part about leaving the MAR blank) because I was new on the case. By the way, there is an index of abbreviations (outdated, no less) and one is "F" for family. That is what I have been writing down in the box. Also, there are no times given for the meds...just once a day, twice a day...no hours. I feel that by writing that, I am saying the ball is in the familys' court. They are assuming the responsibility for the task. I am not charting that they are giving it or not. I will do a better job at writing in my flow sheets that the parents refuse to allow the nurse to adm the medication and that I didn't witness the p0arents adm it.

    I agree that the doctor has to be informed, so she can chart this in her records as well.

    I also want to know in more detail why the mom feels the way she does about the medication (the dad doesn't express an opinion.) Maybe she is just misinformed or had a bad experience with medication before...ect.

    At any rate, I would still like to have a set of guidelines in front of me. I have gone to a HomeCare Educator/Clinical Nurse for a local hospital who suggested I contact look into the NJ State Licensure standards, CMS guidelines, and Nurse practice Act but she thought everything was based around guidelines to general hospital care. It's just that this situation (and many others) would not surface in a hospital...

    Anyway, I have contacted these agencies plus CHAP, JHCO, and NJ state Nurses Association, and am waiting for responses.

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    • Expert

    I believe what you are doing is too much. If this case is beyond your tolerance level, I suggest you do what I do, and that is request to leave the case. I have a line that I will not cross with the parents. Yes, it takes forever to document all their noncompliance. It takes effort to talk to them for education purposes and to inform the doctor and the nursing supervisor. I do all of this to a point. I will not fight and argue with them to get them to do what I want and they don't. When I can no longer convince myself that my documentation is enough to cover me and my license, then I leave the case. I will do or not do what they want to a point. That point is the successful defense of my nursing license. I will not let their bullheadedness deprive me of my livelihood. I just go and they can push around and manipulate the next nurse and I don't have to watch the child possibly suffer because of it.

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    • Expert

    If I were assigned to that case, if I didn't do anything else, I would clean up that MAR, once a day is fine, pick one hour out of 24 and write it down on the MAR, then give the med at that time each day. I believe the nurses that started this case left times off because they are trying to disguise a sloppy hit or miss med administration practice. The supervisor should have corrected this. If the parents don't want the med given, fine, just document it, but leaving no time and no notation is not the way to go. Imagine testifying before a jury and being grilled on that MAR. What a disaster!

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    • Author

    You said it...

    Thanks again for your input!

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    • Author

    I would do the research and write the guidelines myself if I knew how!

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    • Expert

    I'm sorry but from what I've seen in all my years of home health, even if there were clear guidelines in place, home health nurses would continue to do what is easy instead of what is right, what the family member manipulates them into doing instead of what is right, no work at all, if at all possible. I have seen so many nurses who, when allowed by the family in return for who knows what, will falsify their time cards and commit fraud if they can get on that particular case. Others will condone the fraud and do it themselves. A good number of hh nurses will, on a day to day basis, allow themselves to be manipulated by the family. The agency supervisors do little, if anything, to maintain high standards. Instead of being the solution to the problems, they are part of the problems. You have to be mindful of your own practice and your own license when you work in hh. They don't teach that in nursing school.

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    Might I add one suggestion to Caliotter's thorough suggestions? Rather than write "refused," try writing "declined." It means the same thing to us (nurses) but can mean a world of difference for families who are spoiling for a fight.

    *Always* document according to the guidelines you learned in school. If you know that your nursing supervisor is advising you incorrectly, please listen to your inner voice and follow what you know to be best practice.

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    • Expert

    Ditto to what Kate said. The supervisor can not make you change your charting and should not be advising the nurses to go against sound practice. Furthermore, the different nursing supervisors need to get on the same sheet of music anyway. Sounds like they run around like chickens missing their heads. I let them talk away, then I do what I want anyway. What are they going to do to me? See that I don't get another case?

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    It is in the scope of practice for a home health nurse to report a change in the condition of a patient to the physician and to report anything she thinks would jeopardize the safety of the patient, such as unavailable medication. Although it is best done with the cooperation and consent of the parents or family, sometimes that is not possible, and the welfare of the patient is the nurse's first responsibility. I know of more than 1 situation where a patient has suffered harm, even death, because the nurse did not report what she should have. Personally, I would rather walk away from a case because a parent or family was angry at me for calling the doctor, than stand-by, do nothing, and quite possibly watch my patient die or lose my license for negligence. If my supervisor did not advise me to act like a nurse and put my patient's welfare first, then I would walk away from that agency. It is not worth the risk. Nurses, BE nurses! Your patients are counting on it.

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