Consult pharmacist about administering medication

By Dorothyanne Barrym, JD, RN
October 30, 2002

I have a question regarding medication administration. The RN receives an order from the physician to administer medication to an infant. One medication comes only in capsule form, the other in an enteric-coated pill. Because both meds are not available in a dosage small enough for the infant, the nurse is asked on the physician's order to cut the capsule three times, and to cut the enteric-coated capsule in half. Of course, the capsule is filled with medication in powder form and the pill, which is not scored, is to be crushed and mixed with formula. Is this legal?
A.D.

There are no laws governing medication administration, at least not applicable to this situation. This is a matter for appropriate medication administration policy.

Whether this is occurring in the hospital or in the home, a pharmacist should be consulted. If this medication does not come in a form suitable for infants, my first concern would be whether this medication was ever meant to be administered to infants. If it is suitable for infants, then the pharmacist should be able to mix it in some form whereby an accurate dose could be administered.

In no event should the nurse ever attempt to administer either of these medications as directed by the physician in this scenario.

Determination of death

As an RN supervisor in a Florida nursing home, can I deem a situation medically futile to perform CPR if the patient whom I was called to assess is not breathing, has no pulse and is cool to the touch with obvious mottling?
J.U.

Some states have enacted legislation that permits a registered nurse to make a determination of death in the long-term care setting. I can find no similar legislation for Florida, however. Even in those states that permit this nursing determination, the nurse must follow specific policy written by the medical director of the particular facility. The policy must define those circumstances where death is appropriately determined by the nurse.

Ask your medical director for the specific policy and/or written protocol to cover the situation you described, in which the resident's death appears to have occurred more than a few moments ago.

Your best protection in these circumstances is, of course, a do-not-resuscitate order, if that is in keeping with the resident's advance directive. Florida law states that a physician may make the determination not to resuscitate and that nursing home personnel will not be liable for following the order of the physician.

I read this to mean that absent a DNR, an RN must resuscitate until told otherwise by the physician.

Protect your reputation

I am a registered nurse and work in a community hospital. I have had a difficult time in the last year. It started when I felt compelled to report a physician employee of the hospital to the corporate compliance officer. I believed that the physician was charging patients for services that were not provided. This matter has been resolved, but since then it has been difficult for me to work with the physician.

My problem now is that some weeks ago, he wrote a letter to the physician medical director asking that I be transferred from my present department. He went on to say I often intimidated him, plotted against him, was vindictive and put him in precarious situations. He also said I have convinced the administration that he has done something wrong.

This letter was brought to my attention by another employee who found it on the fax machine. It had been lying on an open fax for 24 hours. Several employees within the department read the letter before it was returned to him. He also faxed the letter to an employee who works within the department to type for him.

I informed my manager of the letter, how it was left on the fax and how I felt it was damaging to my career and reputation. It was reported to higher management, and all verbally agreed it was retaliation. I was not given a reprimand nor counseling, and he was told only not to do that again.

No other action was taken. I fear that he will continue to write things that will damage my reputation, career, chances for promotion and name. What is my recourse? I need this behavior to stop. Please advise.
R.M.

You need to contact an attorney in your state and discuss this matter without further delay. The law of defamation differs from state to state. Some states require that you prove damages to maintain a lawsuit for slander (speech) or libel (writings). Other states impute damages when your professional reputation is involved.

More important than a lawsuit, this behavior needs to stop. A well-worded letter from an attorney to this physician may make him see the error of his ways.