They’re prob second. I think I happen to know a lot of people with Aetna.
This is REALLY LONG. Just a story I came across on Reddit. I know we have several medical professionals here and I am a little curious about their thoughts on this.
——-Restrained a patient in the ER, now I’m being investigated by management
I’m a travel nurse working in ER. I’ve worked 5.5 months out of my 6 month travel contract at this location and enjoyed it, for the most part. Good staff, doctors could be better… but overall it’s a good environment. I had full confidence my contract would smoothly run its course, until now, when I was told by a coworker I’m friendly with that one of the doctors is “pushing for an investigation” on me.
(Obviously there are a lot of details to such a case, but I’ll try to narrow it down to the most important developments)
Two weeks ago I had a patient brought in to one of my rooms who checked herself in for suicidal ideation and postpartum depression. She was escorted in by the ER doc, admitting nurse, and a psychiatrist. Once they stepped out of the room, they told me that she was going to be placed on a hold and the doctor was going to order her a PO Ativan so we could try to removing belongings, change them into a psych gown, etc. once she had calmed down as she was presently having a severe panic attack and refusing to change or surrender her belongings as requested. Usually when a hold patient refuses care, we politely but firmly reattempt to do our task and, if they refuse, we escalate to sedative medications or restraints as needed. But, in this case, the team felt it was best to try to try the PO Ativan, wait until it took effect, and then retry once she’d hopefully calmed down. Fine by me, made sense at the time. I gave the PO Ativan. I got a sitter stationed outside the room. Did other patient care in the meantime, spot checked her as I passed the room each time, and waited about an hour before reentering because she seemed just as upset as before. When I entered, the patient immediately became emotional and anxious again and refused my attempts to remove belongings and begin the process for hold patients, as previously mentioned. I verbally updated the MD on the status of noncompliance, and he placed orders for Zyprexa IM. Patient became emotional again upon my attempt to give IM medication and I requested security presence before approaching the patient again. They continued to refuse the injection even while security and additional staff were present and recoiled from my approach. At that point, we placed hands on the patient to lay them down in the gurney to a secure position to give the medication; standard ER practice. The patient began thrashing and resisting us and digging their nails into our hands, shouting loudly all the while. We initiated violent restraints on my instruction at that time. We gave the IM zyprexa once they were down. Afterwards, I stepped out of the room, waited about 20min to assess med efficacy, and placed a verbal order for violent restraints in the chart in the meantime while waiting. The Zyprexa was not effective, so I went to the doctor to request additional meds and update him that we initiated violent restraints 20min prior and I placed the order for him while evaluating med efficacy. He was not pleased that I placed the order on his behalf, but passively agreed with the motion and, shortly after our exchange, charted that he determined the need for restraints after his “face to face” assessment with the patient (which never actually took place as care of this patient was endorsed to him by prior shift MD). He then gave verbal orders for more meds (benadryl and haldol), but I did not finalize the order as the patient was breastfeeding and the EHR was giving me hard stops that did not allow me to process the order. I walked back over and told the doc about the hard stops and he simply said “okay, thank you” and carried on without placing further orders. It’s important to note at this point in the story that the MD never once visited this patient face-to-face as he was stationed at a computer far away from the patient’s room in the unit and never personally assessed the situation himself in spite of the fact I spoke to him on three or four occasions to request more meds, update them about noncompliant behavior, etc.
After that conversation with the MD, I returned to the patient’s room and attempted to verbally contract with the patient for their compliance in exchange for restraint removal as the Zyprexa clearly had no effect and their behavior remained consistently loud and disruptive. Patient refused to contract. I maintained restraints, gave a brief report to my covering nurse, and left for my lunch break. When I returned from my break was when the problems worsened.
I saw the patient’s room was now quiet and two of our lead/charge nurses were in the room (yes, for some reason there was 2 that night. unsure why). I checked the chart and saw only one updated entry by my lunch nurse: violent restraints removed from the patient. Once they stepped out, I spoke to the charge nurses in private to ask for an update. They said “this patient would be more comfortable with a female nurse, can you switch patients with x nurse over there?” Seeing as this patient was on a hold, I knew the patient could not fire me themselves and recognized that this was clearly the charge nurses’ independent decision. I asked for more details. They then changed their narrative and told me the MD had approached them while I was at lunch and told them to remove the restraints because “they’re just here for post partum depression, can we just remove the restraints?” to which they followed. They then told me that the sequence in which I placed orders for restraints was incorrect and that restraining a patient without orders was patient assault and “just, very traumatic and excessive” for this patient as “they’ve never been violent since they checked in and we only use violent restraints for violent patients.” This was untrue and they spoke as though they were present when we attempted to approach patient amicably with medication and to remove belongings when they physically escalated, resisted us, and the restraints were placed. At my request they allowed me to explain my side of the story, but showed no clear sign of honoring my perspective aside from polite acknowledgment.
After trading assignments with another nurse I asked a friendly coworker who helped me with that patient if I should be worried, but they assured me I did the right thing and I shouldn’t be too concerned. Nonetheless I waited anxiously for the next four days while I was off of work to be called in to explain myself… or something of the sort… but it never happened. I came back to work the next week and was not pulled aside or made to explain myself during the three days I worked, either. I figured the ordeal was behind me since they were allowing me to continue my post and perform patient care as usual but it appears I was wrong.
I came into work tonight and the coworker who helped me with that patient spoke to me privately to tell me they were pulled aside during the week and questioned by unit management about the events of that night. That nurse then told me that “doctor x is pushing for an investigation, I’m really sorry dude.” They told me vaguely that they vouched for me but didn’t offer many details.
So, here we are.
Part of my purpose in writing all this is to rant, but my main purpose in sharing is to ask for support and insight. I recognize that, by technicality, I should not have placed a verbal order before getting one, but it is common practice for nurses to initiate restraints when violent behavior erupts and then acquire the order after the fact. I thought this would be no different in the ED of all places, so this sudden concern with me placing a restraint order myself and being loosely accused of “patient assault” is outrageous to me. That said: Where did I go wrong? Where did the charges go wrong? Where did the MD go wrong? Exactly how worried should I be? And what should my next move be since it appears leadership/management is at least looking into this, if not launching a full investigation altogether at this point? I have not yet been approached by anyone inquiring about my care of the patient, but it looks like they’re approaching others already; should I ask to meet with management myself or wait until they approach me?
Thanks for taking the time to read all this.
TL;DR - restrained a non-complaint and violent patient on a hold for SI before speaking to a doctor for orders to do so, spoke to them within <30min to get order. doc was unhappy but allowed it for a short time. eventually MD had charge nurses remove the restraints themselves as MD suddenly felt it was unnecessary. charges then loosely accused me of assaulting my patient and switched me off their care team. two weeks have passed and now it appears an investigation on my care is in development. idk what to do now - pls give advice or commentary.
——
Former ER nurse…
Restraints, or putting hands on patients, are a big step, and require lots of documentation. There needs to be written orders from doctors, and ongoing reassessments by nursing staff to see if the restraints are still necessary. All assiduously documented. The Joint Commission routinely audits the electronic medical record, and that’s one of the easiest ways to get in deep, deep trouble.
Different facilities in different states have different policies, and I could see a travel nurse doing something the way he’s always done, and that not being correct for the people he’s working with.
Having been there and seen panic attacks, alcohol withdrawal hallucinations, schizophrenic or bipolar manic episodes, and who knows what else, I’d always give the health care staff the benefit of the doubt, when someone comes in howling at the moon. But if he did his job in the wrong way, or didn’t document correctly, his job and his license could be in big trouble.
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The nurse said they did restraints without any sort of order. I’d be furious too if a nurse escalated like this without any need to. The patient was being annoying and noncompliant, they werent hurting themselves or others. This nurse escalated like we do for patients slamming their head against the wall.
I’d write their ass up too. Fuck that.
That patient just needed to cool down and be given time to deescalate. That was inconvenient for the nurse, so they went ahead without orders and made sure that patient would think good and hard before sharing their suicidal ideation again
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Since the patient was in a secure room and was neither being aggressive to herself nor property, I’d consider both the restraining and the injection to be assaults.
I didn’t see a clear need to order a forced Zyprexa injection…other than her not respecting their authority and permitting them to continue the intake on their schedule?
Not a medical professional but it seems the patient didn’t get violent until people restrained her. Plus, physically restraining someone going through a mental breakdown to give them psychiatric drugs seems incredibly traumatizing. And for what? Not giving up their belongings?
Seems wrong to me.
It’s tough. She is there, supposedly, for help, but also is refusing that help through non cooperation.
Some of the Reddit responses agreed with you and felt there was not any violence shown until after action was taken. Me being the obedient and compliment person I am though, can’t ever see myself refusing to participate. But she was clearly not in a good place.
Interesting to see how those who deal with this. I am also curious about the doctor never visiting the patient at any point. Is this common in that scenario?
From the patient side, I am definitely careful about telling clinicians what’s going on, knowing that certain statements would have consequences.
Setting aside whether or not there was any wrongdoing, it seems unlikely that this will impact the nurse’s career very much. I’m sure it could but I doubt it will.
It could have repercussions if someone files a complaint with her state’s Board of Nursing.
Like I said, it could. But if I were betting on it, it probably won’t.
Right. Given what some nurses have done for years before getting caught, I doubt this one instance isn’t gonna be more than a slap on the wrist.
What I do know is that I’m so glad I’m not a nurse.
Shit’s just infuriating. CMS creates a rule saying doctors when working with insurers can’t be changed for getting paid electronically. Makes sense. If you’re trying to push digitizing everything you don’t want to tack on a fee for the electronic version or else people will stick with getting checks. The CMS guy who was in charge of coming up with the rules gets hired by a payment processor. CMS puts a rule up saying that doctors can’t be charged, and the former CMS guy calls them up and complains saying that the payment processor isn’t the insurer but is the insurer’s business associate so they can charge fees.
CMS just gives up and agrees with them, so doctors get charged a pretty penny for just trying to do something more efficiently, and all that supposed efficiency just gets transferred to some middle man instead of going to the insurers or doctors.
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So fucking infuriating.
There should be some kind of criminal penalty for this revolving door BS.
system is working as intended
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Healthcare ceos only made four billion in compensation last year.
At least anti-vaxxers and non-smooth-brained people can unite in their disgust.
I was in the ER with dlk9s jr all night. Turns out he has appendicitis. Unfortunately, he’s just a few months short of their age cutoff for surgeries, so he had to be transferred to Children’s Hospital. Now we’re here, waiting for the surgeon.
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Best of luck to Jr.
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