Three Requests in Ten Minutes: Scope, Falsifying a Record, and a Spot on a Heel

Do not give the medication. Giving a medication - and especially an opioid - is a licensed nursing act. In Rhode Island CNA practice this is outside the aide's scope; where a facility uses medication aides, that is a separate certification and a separate set of rules, and it still does not mean handing over a relative's PRN on a family member's word.

Why 'she gets it every night anyway' is not good enough:

• The order is for a reason and a time, and the nurse assesses before giving - pulse, breathing, sedation, pain score, what else she has had.
• An opioid given without that assessment can cause respiratory depression. 'She usually gets it' is not an order.
• Nobody has assessed whether tonight's back pain is the usual pain or something new.

What to say and do:

• 'I can't give medications - that's the nurse's job, and I don't want to hurt your mother. I'll get the nurse right now and stay with her until someone comes.'
• Get the charge nurse, since the assigned nurse is on break. Do not wait for the break to end if she is in real pain.
• Comfort measures that are within scope while waiting: help her reposition, check whether she needs the toilet, offer a back rub if it is appropriate and permitted, adjust the pillow.
• Report the request and the pain to the nurse, and document what was reported and when. Do not laugh it off, and do not agree to 'not mention it.'

Refuse, clearly and without drama - then make sure the truth gets told.

• Never initial another person's flow sheet, and never chart care that was not given. That is falsification. It is a licensing and legal matter, and here it hides a specific harm: a resident who may have been left in one position long enough to start a pressure injury.
• 'I can't sign for your turn. But I've got a minute - let's go do it together now, and you can chart it yourself.' Fixing the gap is better than arguing about it.
• If she still will not do the turn and will not tell anyone, the aide tells the charge nurse: Mr. Kim's 8:00 turn was missed. That is not tattling; it is the only way the resident gets checked and the only way the aide stays honest.
• Do not sign your own name to anything you did not do either, including 'turned and repositioned' for a resident you only looked in on.
• Document only your own care, at the time you gave it. A flow sheet is a legal record, and an initial in the wrong box can follow an aide for a career.

If pressed, the answer stays short and does not become a negotiation: 'I can't sign for care I didn't give.'

(3) Thank him for telling her and say the nurse will look at it. An aide can observe and report - she cannot diagnose or treat.

• Do not apply anything to the heel, do not wrap it, do not pick at it, and do not tell him it is 'just a callus' or 'nothing.'
• Report the location, roughly the size, the colour, when he first noticed it, and that it is on a heel - a classic pressure spot - so the nurse can look at it tonight.
• Help him offload it in the meantime if the nurse agrees: pillow under the calves so the heels hang free, and check his other heel too.

Sorting the three with 20 minutes: This is not a first-come-first-served list. Rank by risk:

1. Mrs. Grant's pain - get the nurse or charge nurse now. Untreated pain is the most time-sensitive item and the aide cannot solve it alone.
2. Mr. Kim's missed turn - either do the turn with Ms. Ruiz or tell the charge nurse it was missed. Do not leave him lying in one position and do not paper over it.
3. Mr. Ellis's heel - a report, not a treatment; it can go into the same message to the nurse.

Then tell the charge nurse what is still outstanding rather than quietly skipping something or charting it as done. Handing over honestly is part of the job; pretending the list is finished is how residents get hurt. Follow the chain: staff nurse, then charge nurse, then nursing supervisor.