Tuesday, December 15, 2009

Behavior/Psych floor three nights in a row

I worked on the psych/behavior unit for the last three nights. The residents are low-maintenance as long as they aren't acting up. Just a few acted out and it wasn't all night.
One of the residents has paranoid schizophrenia and won't take pills. Someone came up with the brilliant idea of giving her omeprazole (prilosec) every morning. Since prilosec needs to be given on an empty stomach 1 - 1 1/2 hours before breakfast, giving out the prilosec falls on night shift, even though I have to start at 4 a.m. to finish by 6:30 a.m., two to four hours before anyone is served breakfast. Anyway, this resident doesn't take pills because they are poisonous. By day three, she was done being poisoned by me and carried on terribly. Doomsday supervisor showed up. Usually, Doomsday would want full vitals and a call to the doctor, because the resident could be having a heart attack or some other event. It's as if nobody believes that a psych patient with behavioral problems could be having a behavioral problem. I left Doomsday with the resident as she complained that I was trying to kill her. The follow-up was that Doomsday thinks that the resident was not having a medical issue, but rather was acting out because of her mental impairments, and I was not doing anything to try to kill her. That's a first.
One of the nurses on the evening shift is not nice- real tough and rough, for no apparent reason. We aren't street thugs, after all. She usually is standing at the desk, arms folded, glaring at me, as I enter the unit. After about five seconds, she starts screaming for everyone to hear, "What is your problem? You're holding me up. Who the hell do you think you are?" The report is, "Nothing's going on." To count narcotics: "I just counted. It's correct. You don't believe me? You think I'm a liar?" Since she doesn't give report and won't count narcotics, I don't know why she just doesn't leave whenever she is "done" working. I put "done" in quotes because she does not do what she is supposed to do. No documentation. No vital signs. Half the medication records not signed for. I've reported her to Doomsday numerous times, always with the same reply, "So don't hold her up."
The day nurses also have severe attitudes. One of the resident's narcotic pain meds were almost gone. I asked the nurse if she had requested the refill since the sticker was pulled, but the meds had not come in. She replied, "When did I refill that? At home this weekend? That's my number one priority when I'm at home, is making sure that [the resident] has her candy." I told her that it was a yes or no question, and that I float and have no idea what happened in the two weeks I wasn't on the unit. She replied, "No." Later, she felt the issue wasn't addressed enough, and came after me with the signature book for the narcotics, screaming, "See? I don't even give her the pill. Why would I refill it?" I told her that the matter had been settled, as I just requested a refill, but that she may be concerned about managing pain, as is her duty. She walked away, mumbling.
The other daytime nurse avoids relieving me. She makes a beeline for the office, gets on her cell phone, and starts making coffee. Then she looks over the aide assignments, sets up her cart, and starts her wound care. I sat at the desk reading a magazine. I had the keys, so she was going to get stuck soon. Finally she said, "I'm waiting for you and you're just sitting there reading!" She has the wait part backwards. She pulled the same stuff this morning. After coming in twenty minutes late and then talking on a cell phone for fifteen minutes, she started setting up her med cart. She stopped midway and said mockingly, "Oh, let me count with you. I wouldn't want to hold you up." I replied, "That's right. Nobody is allowed to hold anybody up." I tried to not make it personal. For the report, I told her about a violent episode that one of the residents had just had. She replied, "So? She does that to me far worse all day, so why do I care that all that happened to you was that she threw juice at you?" I had not asked her to care about me. I was letting her know that the resident had a violent outburst, which is what we do on the behavior unit.
I've told Doomsday supervisor about responses such as these. Her response is that they are not listening to the message and instead are attacking the messenger. This is my fault because I am not communicating effectively. As a result, resident care is compromised and it's my fault because my communication did not persuade the other nurses to monitor and help the resident.
The unit manager acts along the same lines. She writes incorrect orders- missing routes, doses, non-sensical words, etc.- and indicates "noted" without actually noting the order on the medication record. As the night shift nurse, I have to go over the new orders and make sure that they were correctly transcribed and make sense. When someone writes and incorrect order or fails to transcribe the order, I am in the position of having to make the correction. Lots of times I can't correct because I would have to assume too much to "fix" the order. If I "fix" it the wrong way, I'm in trouble. Such a thing happened *again* last night. Tylenol 650 mg liquid. Not transcribed. The problem is that tylenol (acetaminophen) liquid is 160 mg per milliliter. 20 mL is 640 mg; 20.33 mL is 650 mg. Most people write 640 mg liquid because, in the nursing home business, if 20.33 mL is ordered, then you must give exactly 20.33 mL or it's a med error. You would need a syringe to draw up the correct amount and we don't have syringes for that, or even the time. So if I go ahead and transcribe the order, I'm wrong because nobody can really give 650 mg liquid. If I sign off on it, I'm still wrong because it's not transcribed and because it's wrong as ordered. I showed Doomsday. She photocopied it and said she was going to the Director of Nursing. That's why she's Doomsday. Everybody will be getting in trouble for everything. In reality, nobody gets in trouble for anything and nurses keep making the same mistakes over and over.

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