Saturday, January 30, 2010

Money is free, right?

This past week more CT scans, MRIs, dopplers, etc., were done on a patient with a fractured hip because she has- are your ready- mild to moderate pain in the upper leg. She should be grateful that she never had severe pain. She was ambulating from the day I received her and never complains at night, which is when the achy/can't sleep issues arise for others similarly situated.

This is where a lot of those healthcare dollars are going. I really think that someone should stop the use of the pointless, expensive tests.

Thursday, January 28, 2010

Remember to provide nursing care between naps

One the 24 hour report from the unit manager: "11-7 change the patient's diaper overnight."

This is really bad. It's unprofessional. It says that the night shift ignores the resident to the resident's detriment. It underscores the common notion that the night shift does nothing.
There is no accompanying claim that the resident is found wet or soiled every morning. It's a flag to anyone reading the report that the resident is unattended all night. This is not true.

It's similar if I were to write: "7-3 provide food to patient." Which I would never do.

Tuesday, January 26, 2010

iPhone app for medications

I recently got an iPhone. I wasn't sure about my capabilities with the thousands of offerings because the last electronic invention that I mastered was the VCR. I have yet to master a standard cell phone. But I took the plunge and ordered the iPhone. I figured that I could stay in touch with people more. The current night schedule wreaks havoc on the personal schedule and offers little down time to make a quick phone call. Even if I did have a break, not many people are up at 3:00 a.m., receptive to a social chat.
The work-related reason that I wanted an iPhone was for access to information about medications. Today I found an app for Medscape and it seems to offer what I need- drug information, contraindications, and side effects. And it was free! I previously mentioned Medscape.com for the continuing ed. Let's hope that their iPhone app proves to be quite useful also.

Monday, January 25, 2010

Compassion?

A family member stayed overnight, sitting vigil next to her mother as she lay dying.
I administered the morphine as needed, every two hours. As a result, she remained calm and comfortable overnight.
When the next shift arrived, I gave report on her changes overnight, so as to perhaps predict when the resident might finally pass. The death process can follow predictable stages.
I told them that another daughter was flying in and expected at 11 p.m. tonight.
The unit manager quipped, "Well, it will be too late. You suppressed her breathing with so much morphine, so she'll be dead any minute."
She was not in the final stages of dying. There was no reason to suspect that she was drawing her last breaths as we spoke. Throughout the night, I suppressed her thrashing and panting while relieving the painful torture of slowly suffocating to death. Her emphysema and heart failure had suppressed her breathing for years and was finally doing her in. I don't feel that withholding the morphine would result in a longer life. Withholding the morphine would definitely result in prolonged suffering.
When I am upon my death bed, wracked in pain, fighting for each insufficient breath, please ease my suffering with morphine.

Until you came along

The facility is under immense stress because it is due for its annual state survey. It's a surprise visit, but certain dates can be ruled out while others are likely for the visit.
Today was such a date because the particular survey team finished with another facility on Thursday. They would write their reports on Friday and then visit the next facility on Monday. They vary their targets; for example, they don't hit facilities in the same town consecutively and they don't visit facilities owned by the same company back-to-back.
To prepare for this expected visit, everybody was in the facility by 7:00 a.m., running around, "fixing" things to comply with state regulations that they have not even read.
The unit manager of the short term unit rammed me before 7:00. She went off on me for writing an order for heel lifters for a resident. The handwriting did not even resemble mine and I told her so. She said, "I know you didn't write it. But you must have. You worked the 24th and this was written on the 23rd." I pointed out that it was signed off on for the entire month, starting on the first. She replied, "I know that. Somebody just filled it in." I said that I didn't do that. She replied again, "I know that. We fixed it." So then I had to ask, "So what exactly is it that I did wrong?" She said, "You wrote '7-3.' She is not in bed on the 7-3 shift, so that is why it was left off, but you wrote it in. We fix things certain ways for certain reasons, and then you come along and mess it up." I asked, "What shift is it now?" She replied, "7-3." I asked, "And where is this resident right now?" She replied, "In bed." I replied, "So why is it so bad that 7-3 signs that she has heel lifters in bed, not that I wrote it." She said, "Well, it's not. It's just that you had no business adding 7-3." I reiterated that I added nothing to the order. I pointed out that "7-3" was not squeezed in, but rather given plenty of space in between "11-7" and "3-11." She gave up. But she'll be back.
She wants a perfect unit, but knows on some level that she can't have it. She needs people to blame, and I'm one of the chosen scapegoats. I don't know how to fix this. If I found something wrong and was convinced that I had the culprit, but the person denied it, I would not continue insisting that the person was the real culprit. I would continue with the explanation of what was wrong, but rephrase it such as, "If you see this . . ." or "If you are in the same situation in the future, please don't write the order like this. This way is better." But I don't seem to do much right, so this can't be the correct approach.
I would also like to point out that it is ridiculous that the unit manager feels that 7-3 should be exempt from signing off on the "when in bed" orders. The residents are in bed on 7-3; it is that shift that gets them out of bed. The 11-7 shift has to sign off on "when out of bed" orders, even though most residents are not out of bed overnight. If I check off that the order was not met and explain "not out of bed tonight," it's a big deal. Yet every now and then they like to come after me for signing off on a "when out of bed order." I'm damned if I do, damned if I don't.

Saturday, January 23, 2010

The shift always ends

I worked the last two nights on the heavy short-term floor.
The first night took two hours past the shift end time to finish. Probably because Doomsday supervisor worked and went on and on about how this was horribly wrong, that was egregiously disastrous, and the state was about to descend upon the place and we will all lose our licenses.
The second night was a despondent fill-in supervisor. Any problems brought to her attention were met with, "I'm sure you can handle it." I hurried through the night and was finished with almost everything when the next shift arrived. That included an incident report.
On one hand, I like being done when the next shift arrives because I think it makes me seem more together, as if I handled everything well. On the other hand, being done before 7 a.m. further convinces a lot of nurses that night shift does next to nothing.
In the opposite scenario, not being done when 7 a.m. comes around does not seem to convince anyone that night shift has a ton of work. Instead, they seem to think that the nurse overslept on her already extended break and didn't get the med pass started on time.

Wednesday, January 20, 2010

Director a.k.a. RN

I just saved a bundle by switching to Geico!
I'm not advertising for Geico. I mention it here because "registered nurse" was not a career option. They had LPN and LVN, but no RN. I chose "director" because I direct the unit (though most people do whatever the hell they please).
I will now pay less than 1/3 of what I was paying. I'm afraid that it's less service- BUT- I received no service from my other insurance company. I did call my current company first and after a 45 minute hold, they would not even discuss ways to lower the premium.
And because I have (crappy) medical insurance, I was able to opt for the less expensive PIP option.

More hostility

More problems from the CNAs.
None of the three night shift aides were present at the start of the shift. One evening shift aide stays until one night shift aide arrives. The one who stayed last night was working overnight on another floor, thus selected because her staying and waiting would not cause overtime.
I hopped right into the report from the evening nurses. A bed alarm sounded. The aide remained standing at the desk, staring at me. I asked her to attend to the resident. She replied, "I'm not on this floor."
I went to the resident, fussed with her, and got her back into the bed. As soon as I was back at the desk to continue the report, the alarm sounded again. I glanced at the assignment sheet and saw that the aide still standing at the desk was indeed the evening aide who stayed behind. I told her such and told her that she needed to attend to the alarm. She said that she wasn't going to go into a room because if something happened, she would be responsible. I told her that the entire point of her staying was to attend to residents, not just stand at the desk. She said she had to go to her other floor and was unable to perform any work.
I stopped report and attended to the resident until one of the night shift aides finally arrived.
The lagging aide remained on the floor, seated, for another half an hour, before going to another unit.
I told the supervisor when she arrived. I phrased it as, "All three aides were late tonight. CNA [So and So] stayed behind to cover. I just wanted to clarify the role she plays when she stays behind. I thought that she was supposed to attend to residents, but she refused to do so earlier, telling me that she is just supposed to sit here. In fact, she sat on the unit for half an hour after the night shift aides arrived, before going to her next assigned unit." The supervisor said that she needed to address this immediately. She didn't mention it again.
I also told her about the double diapering and denial. She said, "That's an automatic write up." She said that this aide has done this before. I still think that I'll be blamed for upsetting the aide.
They are not unique. There are so many aides that are downright contemptuous of everyone else. They don't do their job, which jeopardizes the residents. When I approach them about an issue, they yell and accuse, and get their buddies worked up. The next night someone else pulls the same nonsense, thinking that I'm a nurse that does not have to be listened to. That's why the aide just stood at the desk, ignoring alarms. They seem to think that they can be excused from their duties by saying that the nurse disrespected them. I hope that administration doesn't see it that way.
I told both aides at the time that I would be discussing the problem with the supervisor so that I could clarify the issues. The strategy that I think that I'm following is that I carry through on my threats and beat them in the race to the complaint department.

Tuesday, January 19, 2010

Who is in charge?

Patients are not allowed to be "double diapered," meaning with two diapers.
Around 2:00 a.m. I found two residents double diapered and told the aide that she had to change the residents and provide one diaper each. She denied that they were double diapered. I couldn't believe it. I counted the diapers to her: "One, two." She looked me in the face and insisted that there was only one diaper. I told her I was writing her up for double diapering as well as refusal to follow instructions.
She then said that she was not the one who double diapered them. I told her that she was making it worse for herself because she was supposed to change them at the beginning of the shift at 12:00 a.m., and she was admitting that she did not change them; furthermore, if she found them double diapered, she needed to report this to me immediately, which she did not.
She couldn't follow the conversation. She asked, "Why am I supposed to listen to you?" I told her, "Because I'm the nurse and I am in charge of the care of the residents." She moped around the unit, muttering, "Nurse? Who does she think she is? She's not allowed to tell me what to do."
The really sad thing is that she will get away with it and administration will tell me to back off before she goes to the union claiming harassment.

Sunday, January 17, 2010

Extra extra extra

I was off last night, which was great. I'm supposed to be off tonight, but was just called into work. I hope that I get paid extra for the overtime as well as the holiday time and a half plus paid an extra day off. I don't mean to sound greedy, but I have bills to pay and I'd rather be sleeping in a warm bed in the dark than working and getting blamed for everything.

Friday, January 15, 2010

Haitian earth quake impacts the facility

More news of death in Haiti- the families of most of the aides. They have lost children, spouses, parents, siblings; the phone calls keep coming on their cell phones and on the facility phones. We are keeping the lines open and allowing them to keep their phones on because phone service is fleeting in Haiti and at any moment someone might be able to get through with more news, usually bad.

Thursday, January 14, 2010

Pass the blame

A nurse's latest stunt highlights the problems with the behavior/psych floor.
For two weeks, on the day shift this nurse has been documenting that a particular resident is a "chronic complainer." Food, people, temperature, feeling sick- she complains about it all. The nurse does not include any interventions she tried, such as providing different food, redirecting the resident, notifying the physician and performing a physical evaluation, etc. Instead, the nurse called the psychiatrist and got an order for xanax 0.25 mg twice a day. The resident is calm and cooperative on the evening and night shifts. This nurse should not have pushed for an order for xanax as the first attempt at treating the chronic complaints.
Second, twice a day means 9 a.m. and 5 p.m. or 9 p.m. The nurse scheduled the medication for 6:00 a.m. and 9 p.m. This way, if there is any fallout from giving xanax, she should escape blame because she won't be giving the medication herself on the day shift. She expects me to wake up the resident and medicate her for anxiety and agitation not present at 6:00 a.m. If I mention this to the nurse, she will bully me and say that the doctor ordered it for 6:00 a.m. That's not true; only on the behavior/psych floor do the nurses insist that doctors specified times of administration and each time was for the night and evening shift, never the day shift.
The next time I am floated to that floor, I want to withhold the xanax and call the physician to notify him. It's within my nursing judgment. But Doomsday supervisor won't like that because I won't be staying "below the radar." The nurse will tell the unit manager who will bring it to administration with "who the hell does she think she is?"
Speaking of reporting me to the higher ups, I was delayed getting out of work today (too many patients) and saw the arrival of the director of nursing and a corporate person- regional director of who knows what. I spoke to both of them. They both insisted that nobody had ever made a complaint about me.
Now somebody is lying. Doomsday tells me nightly that these higher-ups are very upset with me and seeing my name on complaints and hearing my name involved with every problem. She showed me a blurb in the supervisor's communication book written by the assistant director of nursing to the director of nursing that the unit manager had a serious issue with me. I guess that's the only evidence that I ever saw.
I told Doomsday that I was not going to try to fix anything anymore. The facility is due for the state survey any day. In my naivety, I thought that others would be appreciative that I uncovered and fixed an error instead of the state finding it and citing the facility. Apparently, this is not the case. Let the state descend upon them and find these errors. Maybe if they hear it from someone else, they will make the changes.
Doomsday tried to do a heel pad audit overnight. The problem was that what was ordered does not match what was on her list and nothing matches the instructions on the residents' closets and what each resident has on his/her feet is a completely different story. She gave up. I reverted to my help mode, making lists of the orders versus the reality. When the unit manager arrived, I started to mention the situation to her. She cut me off and launched into a diatribe of indications for use of heel pads that nobody is following, different treatments that nobody bothers to do, etc. I replied, "Thank you. You answered the questions I had about heel pads," and I tore up the *helpful* lists I had written. They would not have fixed any of the inconsistencies; rather, they would have gotten mad that I was annoying them with a non-problem that I should have "fixed" [with my magic wand]. The caveat to "fixing" heel pads is that their use is part of the care plan; I can't just order or discontinue them without altering the care plan, and I don't have access to those. One of the unit manager's primary responsibilities, though, is maintaining the care plans.

Wednesday, January 13, 2010

Not understanding

A lot of the aides are from Haiti and have family there. They are very upset over the earthquake.
There was fallout from my changing of the times of administration of two meds on the behavior/psych floor. Doomsday supervisor told me that the complaint appeared in the supervisor's communication book, which is read by corporate, and they will be very upset. She acknowledged that my changes were correct, but that she now has to write a report defending me and what I did. I asked where the report and complaint were when the two nurses changed the medications in the first place to incorrect times. She said that there is no such complaint and never will be, that I do not understand that I'm the one with a target on me. I said that I do not understand why they are complaining that I corrected two mistakes; I'm there to care for the resident, not just hand out pills without thinking, and that I have my own license that requires me to act correctly, not just blindly follow what someone else has set up in error. I also said that I do not understand why any of these people have not been fired with the daily errors that I find. Whenever I work on that floor, I'm in trouble for something that either never happened or that I handled correctly. I told Doomsday that they are bullies and I'm sick of corporate letting them get away with it. She responded, "They treat you that way because you let them." I think she means that if I meekly signed off on everything and said nothing to them, then they would stop filing complaints about me. That's not true. I've tried that and it doesn't work. I go through the proper channels to report problems, and nothing is done. If I document that a bed alarm is broken, they go off on me. If I don't document it, I'm written up for not documenting it. They aren't written up either way.
I told Doomsday that I'm not there to give out pills and go home. I'll be critically looking at each resident and the record. I'll address problems as I see them and refer bigger problems upward. To support the bullies' stance that I give out pills and go home, to get off their unit without causing them angst, supports the widespread opinion of night shift that night shift does nothing but wait for the day shift to arrive, and that the day shift nurses are the real workers, that night shift is some kind of a babysitter that the state, for some crazy reason, requires to be present in the nursing home overnight.
The nurse that worked up there last night told me that he discovered another med error. They took an order to discontinue potassium supplements on a resident whose potassium was too high. That was two weeks ago, at the end of December. They did not transcribe the order to the January record and have still been giving the potassium. (The bullies never carry an order to the following month. Most night nurses don't pick it up. I always do because it's part of the check. Yet for that, I'm targeted.) The resulting electrolyte imbalance can cause cardiac problems, including death. Now if that had been me, I would have been reported to the highest levels. But because the bullies are at fault, nothing will happen. They might even continue giving the potassium just to prove that they think that their prior acts were correct.

Monday, January 11, 2010

Tough customers

The night was fine. I was on the psych/behavior unit. I had not been there since last month. The residents don't call for anything, and that is the problem. You must constantly monitor them because they will attempt to get out of bed or have some other difficulty and the resident and the roommate will never activate the call bell to request help. The aides are upset because the Director of Nursing made a new rule that the floor must be toured every hour. They told me this as if I would say, "Forget that. Just sit there and sleep." I did say, "Forget the hour rule. The floor should be toured every fifteen minutes." As you can imagine, they rarely toured the floor. I have read several studies that conclude that frequent touring of the floor reduces falls and increases customer satisfaction. I have prevented falls myself with tours by finding residents getting out of bed.
One resident screamed and yelled about back pain. I believe her. She has severe osteoarthritis. She calmed down when I took her vitals are positioned her better in the bed.
There was a new resident, described as "alert and oriented x 3." She was much sharper than the average resident, but with early dementia, which resulted in repeated requests for a sleeping pill. I can't page a doctor in the middle of the night for a non-emergent matter, and contrary to popular thought, the inability to fall asleep quickly is not an emergency.
I changed the times of administration for meds on two residents. The day nurses had a fit. I was not going to do anything, but then I decided to go ahead and make the changes because I am correct, I have more authority than they do because of my education and license, and they can just deal with it. I'm tired of their bullying. Rarely do I work on any floor without making changes that others have overlooked. I'm now going to make appropriate changes on this floor as well.

Sunday, January 10, 2010

Ditsy gets out on time, but doesn't get the job done

The night went smoothly, in spite of the forces against it.
I took report from a ditsy nurse. She's ditsy about everything except putting work onto others. Her interesting statements included:

"I signed for her lantus, but I don't remember giving it. So if her blood sugar is really high in the morning, you'll know why." Giggle.

"There was a bottle of phenergan with codeine around here somewhere, but now I just can't find it. Here, sign for the narcotics."

"The bed alarms were not connected? Gee, I never even look at those."

"There was no lactulose in this cart. None. So I didn't give anybody their lactulose."

"These meds are completely out. I was going to request refills, but I can't find the sheet, so oh well."

"These two people were supposed to get antibiotics, but I see that they have allergies, so to be on the safe side, I didn't give them the dose due on my shift."

I had no responses to the above observations.

I did attempt some conversation concerning the floor.
Ditsy: "Mr. Smith had no complaints."
Me: "Why is that on the report?"
Ditsy: "How would I know?"
Ditsy: "Ms. Miller is back from the emergency room. She's okay."
Me: "Why was she sent to the emergency room?"
Ditsy: "I guess she was sick. Or hurt. I don't know."

The three aides were not the best. I woke up one of them every time a call bell was activated. One lied about checking the bed alarms. I showed her several disconnected alarms and asked exactly what she was checking for. One got a resident ready for dialysis, except that she did not have dialysis. The translator explained to me that when I said, "Ms. Smith had dialysis today and is fine," the aide thought that I meant "has dialysis." I reiterated back, "So she does not understand the difference between something that happened and something that did not happen." They all agreed.

Saturday, January 9, 2010

Lack of experience

More on the ankle wound.
Turns out it was a mixed venous/arterial ulcer. This is a fast-developing wound caused by inadequate blood flow and occurs in the distal part of a lower extremity, i.e. the ankle.
Most people at the nursing home have a tendency to label any break in the skin integrity as a "pressure ulcer." Pressure ulcers are considered bad and irrefutable evidence of neglect. I do not believe this, as the skin is an organ and breaks down just as the heart, kidneys, and lungs do. Becoming upset and blaming people because the skin is decaying is like blaming people for pancreatitis.
When I first saw the wound, I thought about venous and arterial ulcers and thought that could be the cause. Unfortunately, I do not have much experience in properly identifying wounds; extremely unfortunately, most of the other nurses at the home also have little experience in properly identifying wounds. I merely described it; I did not give it a name, which is the correct nursing technique. Nurses do not diagnose. Everyone else ran with the pressure sore theory and started a witch hunt for someone to blame: Did it happen on the night shift? Didn't the aide who showered him three days earlier notice the wound? Who changed his socks that evening- didn't they see the wound? And so on. The man walks and turns himself in the bed, which was our first clue that he probably didn't develop a stage IV pressure wound in a matter of hours.
I feel like I have plateaued in my nursing abilities and skills at the home. I originally sought employment in a nursing home because I enjoy working with the elderly and forming long-term relationships with my patients. I have either mastered or become good at everything I need to do. I'm not saying that I'm an expert and that there is nothing left to learn. It's just that I don't get to see or do a lot of highly skilled activities, such as properly assessing patients. Had I been more experienced and knowledgeable, I feel that I could have properly recognized the wound and guided the administration in properly handling the issue.
I spoke to a man whom I knew growing up. He's now in nursing administration in a hospital. He said that the field is tight for relatively inexperienced nurses such as myself, but that I am not considered a brand-new graduate because nursing home nurses have excellent time management and medication administration skills. He encouraged me to apply at the hospital. I think I will.

Pain

Last night was okay. Nobody was hurt, sick, or injured, which is always good. The outgoing evening shift complained that the day shift complained that the usual night nurse did not give out enough pain medication. So I administered pain meds to lots of patients for the 6 a.m. pass. When the day shift came in, I told them to look up the last administration time before giving more percocet. The residents have a tendency to forget accurate time.
I have two scenarios on the lack of pain meds: 1- a resident is asked about pain and denies pain, so the nurse goes on to the next patient. The patient now has the idea of pain in her head, and when the day nurse arrives and starts rounds, the patient tells her that she has pain and has been waiting for the medication. 2- At 6:00 or 7:00 a.m. as I arrive to give the scheduled med, a resident will ask for "the pain pill for rehab." I have no problem giving them a pain pill, but the pill will wear off before they go for rehab at 9:00 a.m., and they can't have another pill until 10:00 or 11. The alert residents realize this and decide to not take a pill at 6 a.m. That is not the story that they tell the incoming day shift nurse, however. They state that they have been waiting for their pain pill for rehab, when what they have been waiting for is the passage of time so that the pill is most effective for rehab.
A resident started screaming at about 5:30 a.m. that she was in agony and needed a pill. I was nearby, but helping another resident take her pain pill, so she had to wait three minutes. When I got to her room, she was snoring. Usually, if someone is in agony, they are unable to sleep. I awoke her to take the pill. She stated, "I've been up all night begging for a pain pill." This is not true. Yet that is the story that her family and administration will believe.

Friday, January 8, 2010

Likability

I'm suddenly seeing a lot on "how to make yourself more likable." I've read the suggestions and was trying to apply them to nursing. I'm finding it easier to come up with the negative, "how to make yourself less likable."

1. Show up late for every shift.
The nurses for the shift before you won't be able to leave until you show up. Or they will have to endorse to your supervisor, making her mad as well.
2. Write incomplete orders and don't carry them out.
The next nurse will have to call the doctor to verify the order, which will also make him mad.
3. Don't fill out any form in its entirety.
You will have people from many different departments coming back to you.
4. Don't do any extra documentation, such as monthly psych reviews or hypnotic summaries.
5. Don't tour your floor and make adjustments or corrections. When someone else brings problems to your attention, reply, "How would I know that?" and keep sitting there, reading.
6. Respond to any issues raised by residents or families with, "You'll have to call social services with that in the morning."
7. Tell the aides to do everything except giving out the meds.
8. Don't answer the phone, unless it's your cell phone.
9. Don't learn anyone's name.
10. Don't give report to the next nurse and refuse report from the previous nurse. Instead reply, "Can't you read?" and "I can read" to each one, respectively. (And I don't mean with respect.)
11. If someone questions you, state, "That's the way I've always done it." Don't be flexible or open.

I learned these traits from my fellow coworkers, some of the most unlikeable people around.

Patient ratio

I just calculated a new statistic.
I earn around $30 per hour to take care of 60 patients. That's like each of them paying 50 cents an hour for a nurse.
The aides earn around $10 per hour to take care of 20 patients. That's also the same nurse rate of 50 cents per hour.
I have long had the minute ratio broken down: 60 patients, 60 minutes in a hour: that's one minute per hour per patient, or not even seven minutes per patient per shift, factoring in my break time (which I rarely get). That includes minutes spent on paperwork, such as verifying new orders and charting. Sometimes the paperwork aspect takes more than seven minutes for one patient. The rest of the paperwork time as well as the bedside care has to be taken away from another patient. When a resident says to me, "This only takes a few minutes," they don't understand that I can only ration seven minutes per person, and they may have already consumed their allotted seven minutes with paperwork. I don't have time to take someone to the bathroom for ten minutes. They just don't understand this. "You're always in a hurry" is a common observation. Well, you'd move quickly too if you had to take care of sixty people.

Scrubs

One of the greatest things about being a nurse is that I get to wear scrubs. I'm not good at selecting outfits to wear. Scrubs are sold in sets or separates that go great together. My place of work allows scrubs of any color or print. When I first started, I only wore white pants with a solid color top. I gradually introduced prints, especially for holidays. One day, after growing weary of the staining and ruining of the white pants, I ventured into the world of wearing colored pant scrubs. Some people only wear white, and that's fine for them, but I tend to get coated in something by the end of my shift.
I don't wear the scrub jackets. They are too stiff and uncomfortable for me, though they do look good on other people, especially when they match the scrub outfit. I prefer cotton scrubs because they are so soft, comfortable, and flexible. I'm wearing a lot of Butter Soft scrubs from Uniform Advantage right now.
The aides also get to wear whatever color or print they choose. The result is a colorful assortment of scrubs running around the place, with residents and families unable to distinguish between nurses and aides. Most people already think that any female in a health care setting is a "nurse," but that's another topic. And some of the aides I work with do not correct people who call them "nurse," and even refer to themselves as "nurse." I have been in other facilities that require aides to wear a specific color, which may help. But the fact still remains that a resident can ask an aide for percocet or to suction their trach, but the aide will never do this because only a nurse can do this.
Doomsday supervisor says that it's best to wear all white so that you are taken seriously. I've seen studies in which people state which uniform, if any, people like to see nurses wear. Some prefer white; some don't care about the color or print of the uniform; while others prefer regular, professional outfits seen in other sectors. I do wish that the facility would consider having the staff of the dementia unit wear street clothes. I've read that people with dementia can be fearful of people who look like medical workers, especially if they have had a long history of treatment for medical or psychiatric issues. In addition, the residents with Alzheimer's are not of this present time and do not understand why a bunch of medical personnel are running around their house. One of the problems with instituting this approach in my current facility is that the staff can't be trusted to choose appropriate clothing and staff is floated too much, requiring that everyone have a scrub outfit and a regular outfit to go to work, which most of the staff could not handle.

Thursday, January 7, 2010

Long night

I left work at 11 a.m., three and a half hours late.
There was a fall. The resident was not hurt, thank goodness. She fell "because I have but one good side." She's paralyzed on one side because of a stroke. Somehow, she still manages to stand and walk using a special walker. She has not fallen in over a year.
I had to write the incident report concerning the fall. I wrote that I was notified of the fall by the roommate. This is true. I was at the desk doing paperwork when I saw her walking down the hall. I've seen her do this maybe once a week, so I was not concerned. She'll usually ask for a pain pill or something to eat or drink. She didn't quite reach the desk when she calmly stated, "My roommate fell, and she can't get up." An aide and I ran down to the room. When Doomsday supervisor read that the resident walked down the hall and told me about the fall, she was not pleased. I said that I did not hear the resident fall, nobody was hollering for help, nobody rang the call bell, and I did not find her on rounds. Doomsday supervisor said that it was okay that a resident notified the staff of a problem; however, this resident is alert and oriented and will tell people that we were sleeping. This is ridiculous. As soon as she stated the problem, we were up and running. Doomsday said that my head was down over papers, but the resident may decide that I was actually sleeping; in addition, administration may ask the residents why they did not ring the bell for help and they might reply that it's useless because nobody answers bells at night. Also, it looks bad that I let the resident almost reach the desk instead of immediately going up to her as she walked. I said that she often walks to the desk for a routine request so I was not thinking that anything was wrong. I felt that Doomsday was grasping for ways people will turn this incident around. They will make it out to be all my fault, regardless of what I write. No matter how many call bells I answer, come morning, someone will complain that their call bell was not answered for twelve hours and administration will believe the, even though the shift is only eight hours.
The second delay issue was the changing of the tubings. Not many on this unit, but still time-consuming and tedious.
The third delay issue was rewriting the ankle incident report of New Year's Eve. They did not want me to write about all of the wounds, just the black wound on the ankle bone. To include the other wounds "would make it seem like his foot was decaying." His foot was decaying. Once the condition was discovered, it was halted with wound care and antibiotics.
The fourth delay issue was once again reconciling the December medication records with January. This should have been finished by now, but was not. There were lots of nuisance errors- nothing missing that was vital.

Wednesday, January 6, 2010

Work every minute but still don't do enough

I started out on the dreaded psych/behavior floor. I don't mind the clientele. What I mind are the aides who walk slower than most of the residents and the in-your-face nurses of the other shifts. Each floor is like a different facility.
I toured one side of the floor, finding bed alarms missing, not turned on, broken, etc. I told the outgoing nurse. She acted surprised, even though we have this same exact conversation every time I relieve her on this particular floor. One of the aides explained that the residents received electric beds today and the bed alarms and sheets were not put back on the beds by the people who installed the new beds. Of course not. The aides needed to reassemble the alarms and the bed sheets. So they were going to wait for one nurse for the night shift to add back all of the alarms?
Another nurse appeared. He said that he was on the floor and his name was on the assignment sheet. It sure was. I told him that I saw my name when I arrived to the floor. He said that the evening supervisor must have just changed it. That sounds just like her. Change my assignment while I'm down the hall and not even tell me.
I was reassigned to the mixed short term/long term floor. Yet another nurse was also assigned. I was able to get rid of a ton of discontinued medications. I was going to write overdue monthly hypnotic summaries, but then Doomsday supervisor told us that she could not justify having two nurses unless we did extra work (what they heck does she think I was doing), so I needed to change all of the oxygen tubing.
Usually, night shift on the other units changes the oxygen tubing on a Wednesday-Thursday night. On the mixed unit, the evening shift does it on Wednesday. You do not need a nurse to do it, but the facility seems to prefer paying a registered nurse overtime rather than hiring a unit clerk for $10 an hour. Taking work from another shift really doesn't make sense. Catching up on our own past-due night shift work does make sense. Also, she waited until right before my heavy 6:00 a.m. shift to tell me about this extra assignment, so I ended up staying overtime for one hour to complete the task.
I also had to write an incident report regarding the black foot wound found on my shift one week ago. I don't know who they are going to blame. The regular evening nurse, who supposedly signs for that resident's weekly body check, told me that he noted the wound upon admission. No, he did not. I checked when I found the wound. I don't know if this is intentional or not, but the facility uses an admission form with a small drawing of a blank body. Wounds or marks discovered after admission can simply be drawn onto the form, as if the wound was present upon admission. The problem with that is any wound, mark, or remarkable physical findings must also be detailed in the admitting nursing notes. For this resident, no note in writing was made stating that he had a wound on his foot where I found a wound on his foot.

Tuesday, January 5, 2010

Chemical restraint vs fixing the bed

Back to work after two nights off. Rare scenario for me and so difficult.
Highlights included: ativan ordered for a resident who became nasty during the day. First, nobody locked up the ativan liquid or had knowledge that this was supposed to be done. The vials were lying in the refrigerator for anyone to take. I attempted to open the locked fridge area, but could not locate a key. Again, nobody else was any help. I ended up giving them to the supervisor. Once I take over for the night shift, I am responsible for any problem that the prior nurses created, which includes unsecured narcotics. Second, an overview of the resident revealed increased nastiness, as well as a depleted air mattress. He was lying on a deflated bed, feeling the metal wires of the box spring. That could make anyone nasty. I got him a regular bed because I could not figure out how to get the air mattress operating properly. The prior nurse admitted that she noticed this bed problem, but just left it.
Another resident had been agitated and combative all day. I found her running around her room. She's very unsteady on her feet and we're lucky that she did not fall. She has a bed sensor which the evening shift consistently sabotages. This night, they had removed the battery. I told the nurse, who was 1-baffled as to why anyone would do that and 2-baffled as to why I was telling her- did I expect her to look at each resident to make sure that everyone was safe and set up correctly? Yes, I do expect her to make sure each bed alarm is activated, just as I have to do when I get in. I told her that I would be writing the situation on the 24 hour report (again), though I know that administration never takes action against these people, never holds them accountable.
After work, I was able to fix a minor problem with my car. One of the great things about working nights is that sometimes I finish on time and can get to places before everyone else. I could hardly stay awake the hour and a half in the garage waiting area, but now the problem is taken care of. One of the drawbacks of finishing work at 7:30 or 8:00 a.m. is that some businesses don't open until 9:00 a.m., so I have to go home, try not to fall asleep, go back, further delay my sleep, etc. It's a rough schedule to work with.
My housemate is still lurking- staying in her room, being quiet, not turning on every light in every room. It's not that she has suddenly become a considerate human being. She's avoiding me. It's conducive to sleeping, but I'm just waiting for her true, noisy, selfish self to reappear.

Monday, January 4, 2010

Another day/night off

I was off last night, too.
It was great to sleep and to do so in the dark. Housemate woke me up at 6:00 a.m. with her noise to leave for work.
I put a bid on a house close to the job. That makes me super-nervous. Moving is one of the most stressful things in a person's life, aside from marriage, divorce, adding a child, and death.
If I get the house, it will save me many hours a week in commuting time. I'll also have to work more overtime, so let's see.

Sunday, January 3, 2010

Day off

I was off last night and am supposed to be off tonight. I asked to be on as back up in case of a call out. I am scheduled every other weekend, but rarely do I not work on my weekend off. Two weekends ago I also did not work. I was called to come in right before the shift started on Saturday, but I had already fallen asleep. Two nurses couldn't make it because it was snowing. Well, how was I supposed to make it? I don't live closer. I could say "no" to the extra shifts, but that's like saying "no" to paying down my loans or buying my own house.
I went out with a friend I had not seen in ages. It was great to catch up. She's newly pregnant and has not officially announced it, but I could tell with the way she quickly refused a margarita and then smirked.
I'm not very social. I prefer to not be around much commotion. I'd rather sit quietly at home in solitude than be out with people everywhere. Maybe that's why I was drawn to the night shift- I don't have people coming at me from every direction and I am supposed to enforce a quiet and calm atmosphere.
I have not seen a lot of my "friends" in a while. I thought that working nights would enable me to run around during the day on lunches, but it doesn't. I'd rather be sleeping. Now with the shorter days, once supper time rolls around, I'd also rather be sleeping because it's dark. People don't understand this.
The schedule is also difficult because I really need two days off in a row to be able to go out without being exhausted and having to rush into work that night. The way the schedule is set up in the nursing home is every other weekend off, with one weeknight off per week. It's nice to get off during the week, but I end up just catching up on sleep, not social engagements.
My housemate has been quiet, allowing me to sleep. On some level, she knows she was wrong to have so many people over the house for so long and to lie about it. But she'll keep doing it. I need to find another place to live. Preparing to move and then moving will be very stressful.

Saturday, January 2, 2010

Incidents of nonsense

Long night. I stayed three hours late. Nothing really happened. Doomsday supervisor worked. She's long winded, so that adds to the amount of time I'm stuck on any one task.
Several marks were discovered on the bodies. Doomsday decided that only one qualified for an incident report. I labeled it a bruise. I don't usually label the mark. I just call it a "purple mark" or "maroon discoloration" because some nurses will argue with me about the label, as if that makes the situation go away. Some people don't like incident reports. I look at them as an extra hour of overtime per incident, kind of like a $50 bonus for each mark discovered. One of the aides said that they should get a cut of the profit for finding these marks. I'll think about it.
The facility is not computerized. The pharmacy is computerized. They print our monthly medication records. This task is done around the 20th of each month; therefore, any changes for the last third of the month are not reflected on the printed records. They must be handwritten onto the records. Sounds tedious but simple, I think. Yet most other nurses are wholly incapable of writing orders correctly, can't transcribe them accurately, and can't be bothered to write them on two months of records. I discovered many errors overnight stemming from this conversion problem, so I had to stay and fix them.
On some level, administration is impressed that I find so many of these problems and correct them. But on another level, there is now a paper trail of the error for a state inspector to see. Administration is torn between letting stuff go, hoping that an inspector won't notice, and finding and fixing these problems before the inspectors arrive and find the problems. Because I am the nurse finding the most errors, I tend to get the blame for making the errors obvious. Yet the cause of the errors is never addressed. Thus the same errors happen month to month. I'm good at finding the mistakes because I know just where to look because there are patterns; also, certain nurses make certain mistakes in spite of being told repeatedly about their error pattern.
I relieved two new LPNs. They had been aides and attended a nine month course to become LPNs. They felt that being a nurse would be better because nurses do less for more money. They quickly realized that a nurse, unlike an aide, cannot leave until all of her responsibilities have been satisfied and that a nurse, unlike an aide, is responsible for everyone and everything on the unit and faces loss of license, lawsuits, and possibly criminal action for failing in her duties. They still do not fully grasp a lot of concepts. One of them placed fentanyl patches on two patients as scheduled for her shift. She must have missed the day in nursing school when they told you that you must remove the old patch first before placing the new patch. So I inherited people receiving double their narcotic doses. The other LPN did not check that the fentanyl patches were actually in place on her patients. Keep in mind that she signs that they were located. I could not find the patch on one resident. I asked her where it was, but she had no idea that she was supposed to check for it, even though she signed that she did so in the medication record. I am particularly concerned about this resident because her family does not want her to receive pain medication and has threatened to remove her fentanyl patch. Fentanyl is a controlled substance. The facility should have contacted the police when the family first started removing the patch because they were interfering with the care of a resident, which is abuse; they stole something, the patch, which belongs to another; and they were in possession of a narcotic without a prescription. But the facility refuses to take a stand against them, so the family continues to run amok in the facility and when they can't physically make it in to harass people, they call on the phone.
Another resident, who is in the facility because she is senile, decided that she waited too long for her clean diaper to be replaced and called her daughter with her senseless complaint. I was in the room with the resident assessing the situation when the daughter called the desk for me. Well, I can't be in two places at once, so I missed the call. That angered the daughter further, which makes no sense. She can't have it both ways. I'm either at the bedside delivering care to the resident, which is what they claim they want, or I'm sitting at the desk to answer their ridiculous and pointless phone calls.
Once home, the many house guests of my housemate were leaving, finally, thank goodness. Now I can get some sleep. The housemate wasn't home, of course, but she does not understand why she should be home to receive visitors. I dread who she'll find next to stay at the house.

Friday, January 1, 2010

New Year, same old

Happy New Year!
I worked overnight- holiday pay. We celebrated at midnight with the sundowners- the residents who have reversed circadian rhythms and are up all night. The day shift characterizes sundowners as "the night shift won't allow them to go to bed."
For some reason, two nurses were scheduled for the unit I was on. There were no incidents.
The fallout from the infected foot was that the feet of every resident must be checked. By me. As if I caused the infected foot. The feet should be checked every day anyway. I don't understand how an aide would change someone's socks and not notice a large, bleeding wound on the ankle. Maybe that's why there was another nurse- so I could check the feet. I found no serious issues.
On the first of the month, the medication records, which are monthly, must be converted to the new month. It actually went smoothly this time, at least on the floor where I was last night.
I left work on time. At home, the "house guests" are still there. I would never invite a bunch of people to stay with me without clearing everything with my housemate and making sure that she was not inconvenienced. She is not aware of such a courtesy, though. They were out late celebrating the new year and were still asleep when I arrived. Remembering how many times they woke me over the last several days, I woke them up because I'm just so darn noisy. I also coughed, dry heaved, and wiped my nose on my hand and then touched everything, complaining that I caught the flu from my patients. Several of them stared in horror. I don't know what I'm going to have to do next to get them out.