Sunday, May 15, 2011

My Last Day At Work

י״א באייר תשע"א
Mab 13

For those of you who don't yet know, I was fired (again) from my job on Friday. This is a walk through my last day at work.

In the morning, walking into the building and back to my office at the back of the building, I said "good morning" to everyone, staff and residents alike, I passed on my way. This is my morning ritual since usually during the day I am so focused and tunnel visioned that I often don't have time to chat or speak much to people. There are typically two particular residents who are among this group every work day - they smile when I walk through the double doors in the morning, saying sometimes "howdy-do" and "good morning" to me before I can get it out first.

After getting my purse settled and calendar out for the day in my office, I went back out to the nursing unit to gather up some information kept at the nursing station - heading back to my office following doing this, one sweet lady resident motioned for me to come over. I did. She was smiling, with tears welling up in her eyes - she said to me "you are the one who gave me the dreamcatcher, aren't you?" She was trying hard to hold on to the memory of it. "Yes, I am," I said. She said, "it is so beautiful" and she asked if it was handmade. I told her that yes, it was handmade by a Cherokee artist (she herself is proud of her Cherokee heritage). She reached out and I took her hand. She squeezed my hand.

Later that morning, one of the corporate nurses called and was upset with me because I had made corrections on legal clinical regulatory documents before signing them off as complete with the authority of my professional license. My understanding of a regulatory requirement governing the signing of these documents differed from her understanding of it, and during our discussion, when I tried to explain the rationale for my position, she cut me off saying, "NOW you be quiet and LISTEN to me, I AM TALKING TO YOU NOW." She didn't want to hear what I had to say and spoke to me as if I was a child in kindergarten and not a professional nurse certified by the national professional nursing organization (American Association of Nurse Assessment Coordinators) for this area of nursing specialization as knowledgeable in the area under discussion. I listened to her as she spoke. When she was finished, I again tried to explain the rationale supporting and forming the basis of my position - she hung up the phone on me in the middle of my attempted explanation.

Since I am AANAC trained and certified regarding the regulation under dispute, I could not claim ignorance as to how the regulation is to be understood and just agree to understand it the wrong way because, in her words, "she has been doing this for twenty years and I (she) know (knows) how it is to be done" and her way of understanding is not wrong (according to her) and if she was wrong "don't you think state would have pointed this out to us it already?" (Is she kidding that because clinically focused state surveyors haven't noticed it yet that this supports her as being right? Scary thought, but I didn't say it out loud. I suppose it makes sense - NOT - to let State be the one responsible to find your errors for you before you do. Just like it made sense, that until I came, no one there knew we were supposed to do an OMRA (Other Medicare Required Assessment) for residents who were no longer receiving therapy yet who were being held on Medicare A for skilled nursing services - my assistant didn't even know what an OMRA was - trained by the corporate nurses, she had never been taught anything at all about them or that an OMRA even existed as an assessment that needed to be scheduled in some specific situations. (Facilities are required to do this OMRA assessment solely because Medicare doesn't want to continue paying a high daily reimbursement rate for rehab services when a resident is no longer receiving rehab services.) And just like, before I came, their computer system was failing to capture the short-stay assessment code - which functions to pro-rate rehab based reimbursement levels - the failure to capture this code resulting in the loss of alot of money for the facility over the period beginning last October 1 through the time when I found the error and got it fixed when our MDS Office called the software company who downloaded some files for us to correct the problem. I shudder to think what will happen when this facility's turn comes up to be RAC audited, since the corporate nurse thinks the state is on top of MDS coding dates and all is well. Clinical quality focused state surveyors aren't on top of nonclinical MDS regulations, but assuredly, reimbursement focused RAC surveyors will be.)

She called back about 15 or so minutes later. I respectfully disagreed with and maintained a professional tone with her throughout it all, suggesting several times that the solution was for some other nurse who felt comfortable with her way of understanding the requirement (like herself, for instance) to sign off on past documents done this way (since she didn't want me to make the correction I felt I needed to make before signing current documents which had been prepared by my assistant as she had been taught to do by the corporate nurse according to the corporate nurse's understanding) and in the future, I would sign off on documents dated according to my understanding as to how it is to be done. She agreed that we would do this (since she could not indeed dispute that my way was incorrect as I could hers). I thought we had agreed anyway. She said she agreed with this solution. I was also pleased with myself that I had done the job I believed I was hired to do - contribute my expertise to upgrade existing MDS processes at the facility and for the organization.

This corporate nurse then faxed me a page from the RAI manual with underlined points which she considered to be supportive of her understanding (the points she underlined did not speak directly to the point of dispute at all - how early the documents could be signed off by the responsible RN as fully complete - her underlined points spoke to how late the documents could be signed, which was not the date under dispute). On the fax, addressed to both myself and my assistant, she wrote that I should contact her if I had any more questions or concerns. I faxed back my response reiterating my position (that I could sign off with my professional authority on a final MDS completion date no earlier than the date after the final date of clinical observation (called the ARD or Assessment Reference Date) - thus making the earliest date I could sign off to be at least one day after the final date of observation, because you can't complete the data summary document until the period of clinical nursing observation ends - which runs through 11:59 PM on the last date of observation) and I myself had underlined and highlighted the portions of the page she had faxed initially which stated that the period of observation runs through 11:59 PM of the last day of clinical observation (implying that the period of observation is not over until 12:00 AM on the date following the last date of clinical observation (a fact which clearly supports my understanding of the regulation and does not support her understanding of the regulation, where she understands that is perfectly okay to sign off on the last day/date of clinical observation itself which itself remains squarely within the period of clinical observation). I called her cell phone (as she had instructed me to do if I had any further concerns) and left a message that I had faxed her back my response to the information she had sent and summarized what I had written/highlighted on the paper in the phone message in case she wasn't near her fax machine.

As I had walked back from the front office where I used the fax machine, a kind gentlemanly resident motioned for me to stop a minute. From his wheelchair, he was smiling up at me and with a chuckle he said, "why does a beautiful woman like you always wear black?" I smiled and chuckled back at him, explaining to him it was part of my spiritual practice. We exchanged a few friendly brief bantering words, as I hugged him (through my hand gently squeezing his shoulder), and then I walked back to my office leaving him with a sweet smile on face.

Back at my office, this corporate nurse called me back and we rehashed the previous discussion. At the conclusion, we agreed as before - that another nurse comfortable with signing off according to her understanding would sign off on past documents, and future documents would be prepared and signed off according to my understanding, since I would be the RN responsible for signing them, and since it would be under the authority of my professional license which the documents were completed, and since my way of understanding was not disputable nor incorrect.

After this, I went out to gather some data. As I was gathering data, the assistant administrator walked up to me, indicating that she and the administrator needed to speak with me in the administrator's office. In the administrator's office, I was concisely informed that a decision had been made that I "am not fit for the organization and therefore your (my) employment is terminated, effective immediately." I simply said, "ok,", walked out of her office, gathered my things, and turned in my keys.

Simply, wow. I can't honestly claim that I didn't expect something like this to happen - been down this road before.


kim said...

Wow is right. Seems to me you two had a perfectly logical arrangement on how to sign off on the documentation.

I agree, I shudder to think what may happen if they are audited.

Doing the right thing apparently is the wrong way?!

Myfanwy said...

Being right on this issue and standing my ground on it (and implementing the practice of doing the required OMRAs and fixing the long-standing computer error responsible for losing the facility lots of money and siginificantly increasing the reimbursement generating Medicare-A length of stays (and thus the Medicare-A census) just within the first month of my employment) was much too much for this corporate nurse to accept I think.

Myfanwy said...

I won't be surprised if this facility goes bankrupt after it is RAC audited and the government happily takes back its Medicare money because alot things are still yet to be corrected and made kosher.

Katlaya said...

I was fired once in 26 yrs of being an RN and that was the last job I ever had. Unfortunately, they needed to fire one of the higher paid nurses so they twisted situations and down right lied about others to get me fired so they didn't have to pay unemployment. My being a witch in a bible belt area didn't help my case, either. That was May 14th of 2008. Now I am very happily retired and glad to not have to be a nurse anymore. I was one of the founding members of PAN. Not sure if you belong to them or not, but it seems to be a great organization.

Myfanwy said...

Yes, it is hard for experienced competent RNs to find work these days. It is especially hard if your aren't cut from the common mold, as are you and I. I don't like being a nurse either. I live in the bible belt too. I'll check out PAN - thanks.

Dare to be true to yourself.