Thursday, February 25, 2010

That 24 hour chart check

I'm growing increasingly tired of the antics of other nurses.

This morning, one of the LPNs who has yet to write a correct order, once again went off on me for flagging her orders. Her usual errors include: omitting the route of administration ("everyone knows it's oral unless you write something else"); writing one frequency on the order sheet and another on the medication administration record; writing the order on the wrong patient's chart; writing blanket discontinue orders and then specifically carrying them out on the medication administration order ("you know what I meant.")

She said, "You must have nothing better to do than go through all of the charts and find mistakes."

I told her she was exactly correct. It's called the 24 hour chart check and is performed at night by the night nurse, i.e., me. I asked her how she wanted me to handle the errors in the future.

She replied, "Just leave them there and the next nurse can sign off on them."

I told her that it didn't work that way, that I was responsible for the orders on the particular day that I worked, and that I could not ignore erroneous orders, nor could I sign off on them.

She still didn't get it.

But in a way, she's right. She has never been spoken to by administration about these daily errors, so it looks as if I am the only one with a problem.

I can't just sign off on all of these errors. If a patient suffers a medication error, I can also be blamed because I checked the order and signed that it was correct. If I orally inform the nurse of the error with her written order and she does not correct it, I have no proof that I caught the error; rather, it looks as if I didn't do the chart check, and that the error could have been prevented had I bothered to do chart check.

The director of nursing considers this to be womanly cattiness, so approaching him is useless.

Another nurse discontinued a few orders that never existed in the first place. I can't sign off on their being carried out correctly because they are, by definition, impossible to carry out. On the 24 hour report, I asked for clarifications. She said, "That's the most important thing of your shift? You're kidding, right? I'm not clarifying anything. Who cares? You make mistakes, too."

I told her that she can do as she wishes with the orders, as my name is not associated with them, hers is.

She said, "You don't support your coworkers."

I told her that I let her know that orders she wrote are incorrect so that she may correct them, but I cannot guess what she meant and do it myself, if that's what she means by "support."

She declined elaborate on how she expected me to handle such phantom orders.

I also documented that certain patients refused medications. She replied, "So? Why would other people care that you can't handle a med pass?"

I think that she lost sight of the resident and instead focused on slamming me. The result is that we now have several residents with current orders that maybe should have been discontinued; and we have several that are not taking their meds and their doctors will not be told. Perhaps she is content, though, thinking that she proved, at least to herself, that I am the jerk for raising such issues.

Sunday, February 21, 2010

Stop making trouble

I found a fresh scab on a resident. Put it in the nursing notes and did a brief incident report.

Told the incoming day shift nurse about it. She retorted, "That's been there. It's clearly documented upon admission."

Well, the scab was not documented at any time since the resident was admitted three weeks ago. I checked before writing the incident report. There is really no need for the day nurse to be concerned; it's not as if she would be blamed. I usually write one or two incident reports per shift. The Director of Nursing wants it that way.

The next day, I checked the resident's chart, and sure enough, the nurse had scribbled in "scab" on the diagram of the body at admission. Another nurse did the admission, but it didn't even faze her to attempt to conform to his handwriting. The scab is not mentioned in the admitting nursing note, but she didn't scribble in "scab on left trunk" in a little gap.

And yes, she will get away with it. Nobody will even tell her to not alter the medical records. The thing that really gets me is that there was absolutely no need for her to go back and doctor the record. It's as if she just likes to prove that I go around making trouble where none exists.

When the Director of Nursing hears of this, which the night supervisor will tell him, he'll call it a "cat fight." He will see no problem with altering the record, but he will see a problem with my trying to create trouble for others by pretending that an old wound was new. As if I have time to write fake incident reports.

Tuesday, February 16, 2010

Evil nightshift

Same thing again, but with a different resident.

"I can't breathe." Vitals normal, can talk, walk, etc.

Had to have her taken away to the emergency department.

Then someone fell. Didn't get hurt, but it's still more paperwork.

We're doing "bowel and bladder" training on a resident with recent-onset incontinence. I hesitate to report accidents in continent people because the unit manager says the same thing- "She's only incontinent at night because night shift doesn't help her to the bathroom." I confirmed with the main nurses on the day and evening shifts that the resident is incontinent on their shifts also. Amazingly, night shift completed their information for the last week. The other shifts did not, which is not unusual. But this gave the unit manager the opportunity to fill in her version of the resident's ability to hold onto her urine during the day and evening shifts. I watched her fill in "continent" for every day and evening shift for the last week, with only the night shift reporting incontinence. It's as if she just wants to persecute the night shift, rather than figure out why the resident is losing control of her bodily functions.

Monday, February 15, 2010

Comedy of errors

Same unit. I become faster with the med pass with each consecutive day.

Before the 6 a.m. med pass, we had to deal with the usual. Heel pads not on the same residents. No protective sleeves on the same resident with the same aide not putting on the shirt I provided, pleading ignorance. Resident at high risk for falls- still with no chair alarm. The day nurse showed it to me. The aide had thrown the bed alarm in the corner and put the chair alarm on the bed; hence, still no alarm on the chair. Comedy of errors.

Around 4 a.m., a resident said she couldn't breathe. She could breathe, talk, drink water, and issue commands. I sent her to the hospital. In general, we are not to use the town's volunteer ambulance squad/911. I called our customary ambulance provider and was told that they did not have an available ambulance. So I activated the 911 system.

The responders criticized me for: 1- there is nothing wrong with the resident; 2- I called a private ambulance first.

I just can't seem to win.

They took her anyway because, as I explained, if she started to crash, I had nothing but oxygen to give her, which was not helping her anyway.

Sunday, February 14, 2010

Must be nice having no responsibilities

I've been considering trying to get hired to work in a hospital. I shy away from hospitals because I'm more comfortable in a nursing home setting because I worked in one for years before becoming a nurse. Around here, nursing homes pay more than hospitals. But hospitals seem to have more reliable ways to increase one's salary, such as annual pay raises; extra for working evenings, nights, weekends; increases for having a degree; increases for becoming certified in a specialty, etc. With my current nursing home employer, I can basically expect to be earning the same hourly rate for years to come.

I view hospitals as stricter. You have to be on time, you have to give the medication within a certain time frame, you have to carry out orders when given. Yet I am strict with myself in the nursing home setting, while others are not, and that is a big part of the tension I feel there. I arrive on time, usually early. The outgoing nurses don't realize how early I am and get upset if I tour the floor first. Sometimes they throw the keys at me and go to leave, realize that their shift is not over, and then sit down and read or chat on their cell phone, with their undone work sitting there, endorsed to me. I don't think that this happens often in a hospital. I'm sure that other bad things go on in hospitals. I hope that I would not be jumping from the frying pan into the fire.

Last night I toured the floor and found two residents with their heel pads on shelves instead of on their feet. This is the usual finding. The nurse on each shift signs for the heel pads, yet when confronted, acts as if they have nothing to do with ensuring that the aide places the heel pads on the feet. I told the evening nurse that the heel pads needed to be placed on the two residents. She repeatedly slammed her hand on the counter while shouting, "You heard the woman. She said she wants the heel pads on now." I calmly stated, "Actually, I want them on when the resident is put to bed and not four hours later." She didn't get it.

One resident got heel pads; the other one did not. I had placed the heel pads on top of the bed, over the resident's feet. I told the night aide for that resident to put the heel pads on her. On the next round, I saw that the resident had been changed, but the heel pads remained on the bed. I asked the aide why she had not placed the heel pads on the resident. She said, "I didn't think that I had to do that." I asked her which part of my instructions of "Place the heel pads on Ms. Smith" made her think that she was not supposed to place the heel pads on Ms. Smith. She said, "I thought that the evening shift was supposed to do that." I answered that they were, but they didn't, so we needed to ensure that the heel pads were in place by placing them. She replied, "If the evening shift didn't do it, why does night shift have to do it?" Please keep in mind that this aide, like most of the aides, works every shift, yet still cannot connect the dots and realize that an omission by one shift must be corrected on the next shift.

Another resident was missing her protective arm coverings. The evening nurse for that wing was unaware (of course) and had no idea where they might be. The alternative is to dress the resident in long sleeves. I found a pajama top with long sleeves and gave it to her aide to put on her when she woke her up for hygiene care. Later, I checked on the resident and sure enough found the pajama top lying on a table. I confronted the aide. The aide said that the resident refused and because of "resident rights," she didn't put the top on her. I told the aide that the resident is confused and cannot appreciate the need for the long sleeves; furthermore, when she is unable to complete an assigned task, she needs to inform me immediately. The aide stated that she had no idea that the resident was confused and that she was supposed to tell me if she didn't do something. She chose to follow the senseless ramblings of a person in the final stages of Alzheimer's but not the directives of the nurse. I guess the resident's shouts of, "And get the are up sometime over yes," and "Geeeeee!" were not enough for her to suspect impairment.

This is what I have to work with. A bunch of people who rather use energy to come up with lame excuses for not carrying out simple tasks instead of just doing the work.

Wednesday, February 10, 2010


I've been very tired lately. It's very hard to work nights. Sleeping during the day is not as restful as sleeping during the night. When the rest of the neighborhood is calming down, succumbing to their sleepiness into warm, dark beds, you have to inspire yourself to be energized, dressed in scrubs, and driving in the cold to work under fluorescent lights, met immediately by never ending demands from patients who seem to have no idea that midnight is the opportune time to sleep.

The only patients who do seem to be deeply asleep at midnight are the ones who are supposed to get medication at midnight. It is next to impossible to get someone to swallow a pill when they are sleepy. It's also very difficult to wake up anyone over the age of 85. My favorite is when the outgoing evening nurse tells me, "I just gave Ms. Smith her sleeping pill, so don't wake her up." This implies that I cruelly go around the unit waking people up for no reason other than to be mean. When I tell her that I have to wake up the patient because she has medication due, the nurse usually says, "Oh. Can't you just wait until morning?" Well, no. The midnight meds fall on the "every six hours" schedule. I can't hold a 12 a.m. med until 6 a.m. because then I would be doubling the dose. I also can't hold the medication and write, "Held because sleeping." If I can't wake someone up, it looks like they are in a coma or dying, and I'm supposed to take vitals, call the MD, transfer to the hospital, etc. Except for antibiotics, most other 12 a.m. meds do not need to be scheduled at 12 a.m. Yet when I endorse to the day shift to contact the doctor for a readjustment in the schedule to facilitate the patient's sleep, the response is the same: "Night shift is so lazy. They think it's terrible if they have to give out a few pills when they get here." So I continue having to wake up patients.

Thursday, February 4, 2010

Huh? What?

The last several nights have been the same thing: sleeping aides who don't hear call lights, bed alarms, or requests for assistance. Then they actually get mad when I wake them up. And mad when I ask them seven times to do the same thing.
Doomsday supervisor stands behind them. "It's snowing outside," "She didn't realize," "She worked a double. She's tired," are the excuses she has for them. Nobody fell, thank goodness. If somebody had fallen, I could not have written in the explanation box, "Resident fell because the aide was too tired (and self-righteous) to get up and help the resident to the bathroom."
She finally yelled at two aides, "Get up! If that resident is on the floor, both of you are in serious trouble." A bed alarm was sounding in a high-risk room and both aides remained seated. I doubt that anything would have happened, though, if the resident had fallen. Doomsday would have turned it around on me, saying that as the nurse, I was aware that the aides were not answering bed alarms, so it became my responsibility to do their job for them.
It's becoming increasing frustrating and dangerous to work here.