Neglect...LPN was fired, RN was not

[KacyLynnRN]

I wanted to get everyone's opinion on a heated debate at my workplace. I work in a large hospital's Med/Surg unit. Usually 8-9 patients are lumped together as a "team" with an RN, LPN and CNA on each time. At night, it can be 12-14 patients, often with only an RN and LPN. Usually you 'split' the team with the LPN taking some patients, the RN taking some patients, and each person doing total care for their patients. One night about a month ago, an RN and LPN had 'split' their team. One of the LPN's patients was found dead on the floor at about 5am, they called a code but he had been dead awhile and rigor mortis had already set in. The patients was in his 60's and a GI bleeder, he was being prepped for a colonoscopy the following morning. I heard through the grapevine the hospital had done an autopsy and the patient had fell on the floor, hit his head, and died as a result. He had been dead about 3-4 hours before he was found. As a result of this, the LPN who was responsible for this patient was fired. The RN on the team recieved a verbal warning, but otherwise she was not disciplined. A lot of people at our work complained to our manager, and she said the LPN has a license too, and therefore she is legally responsible for her patients just like the RN is. I am an LPN but am also a full-time RN student and will graduate in 11 months with my RN. The LPN's at work have been bad-mouthing the RN and our manager, saying that the RN is over the LPN, and she should have been fired too. I personally agree with our manager...I feel that while I am not an RN, I am an Licensed nurse and with that comes personal responsibility for my nursing actions. A lot of my LPN peers disagree, so I have kept my opinion to myself for fear of my coworker's backlash. It is really a HOT topic at work now. What do you all think?? Am I right in my opinion?

[Tweety, BSN, RN]

One question Tweety...how do we know it was a safe assignment??? If you as the RN didn't see an LPN go into a room all nite...what would you do?

And just because someone is there, doesn't make them competent...nor does it mean they are able to handle the load assigned to them.

I understand where you are coming from. However...I do feel that 12-14 pts...is too many pts...... if I were the RN , and was going to delegate. I would prefer to have the LPN do meds, and this would've alleviated the problem of this pt. not being seen for 3-4hrs....hopefully. JMO

Depends on what is the established ratio for the unit. Again, I have only my own perspective and how LPNs are utilized here, which is basically as total care providers with an assignment of their own. Our ratio on nights is six. We don't do teams, but as the nurse practice act dictates, all patients are to recieve an RN level of care, so there is an RN assigned to each LPN. Usually it's the charge nurse. So that RN has his six patients and the LPN has his six patients, that's 12. 12-14 patients for two licensed profressionals is not unusual here for med-surg. I agree it's not necessarily the safest of ratios.

It is the hospital's responsibliity to maintain competencies, so say an LPN floats to me that I've never met or worked with before. I'm not going to refuse the assignment because I don't know him. I'm going to have to trust he's passed all his competencies, and holds a valid LPN professional license. Where my job comes in, "is this a safe assignment", most of the time med-surg patients can be handled by an LPN, so usually it's not much of an issue.

Do we know if the original OP's assignment was safe and the nurse was competent? Ultimately we don't really know. Often we don't really know until we get into the assignment what's going on. But if I delegate you to do the care for a group of patients, I'm delegate that you round on them q2h or however often their condition dictates. I'm not going to take care of my six patients, and the LPNs too. Until I know of a problem, then I feel I don't deserve the same kind of punishiment.

It does get a little shakey when the LPN makes a fatal error or is incompetent. But if RNs were being dismissed or disciplined for every LPN error, or every fall on the floor, we'd be in trouble.

I wholeheartedly agree the safety of the assignment should be investigated. Perhaps the RN should have taken the GI bleeder because of the potential for trouble. We can always second guess ourselves, I do it all the time when there's a bad outcome on my unit. Drives me mad.

So I still maintain that the RN shouldn't have recieved equal "punishment" for the LPNs negligence. The key word being "equal".

[Tweety, BSN, RN]

I think the problem with the RN lies in the fact that it is stated that this is a TEAM nursing floor. If the hospital has delegated it to be a team floor, I can not understand how you can justify splitting the team for any reason.

If they can justify splitting up then, yeah, I think the LPN is solely responsible for the patient.

I don't think that in this situation the RNs responsibility was solely to supervise the LPNs work. In my opinion both nurses should have been providing some form of care (even if its only checking the patients for signs of life :stone ) throughout the night. That is just my understanding of how team nursing works.

I am not trying to defend this LPN...it is obvious that she did a poor job. Only because it is a team nursing floor do I think that the RN should have been in the room enough to know what was going on despite the fact that it wasn't reported to her. It sounds like she was assigned as a direct provider of care to the man. If her assignment were solely supervisory in nature, it would be a different story.

The main problem I see with team nursing not working well is that these patients in med-surg, need head-toe-assessments focused on their diagnosies. It gets a little tough and night when there's 12 patients in a team for one person to do all of that, and to chart those assessments. I think this is why the natural response is to utilize the LPN's assessment skills and split the assignment.

But I see your point, if there's two or three people in a team, there's no excuse for patients not being checked on. The RN should have been more aware. I still maintain, though the RN should not have been fired along with the LPN., IF the assignment was appropriate.

[Sheri257]

It does get a little shakey when the LPN makes a fatal error or is incompetent. But if RNs were being dismissed or disciplined for every LPN error, or every fall on the floor, we'd be in trouble.

So I still maintain that the RN shouldn't have recieved equal "punishment" for the LPNs negligence. The key word being "equal".

I agree with you. But if the regulations state otherwise, it probably doesn't matter. What's going to happen if you're called before the BON or sued by the family?

Are you going to argue that the law/regulations don't apply to you and that it's not your responsibility when the law says it is? Not a good idea.

If Brownms46's links are any indication, it's going to fall on the RN no matter what. There goes your license, because the law says you're ultimately responsible for the LVN. And, the hospital may be even more liable (or, at least not look very good) for not firing the RN, if the law says she's ultimately responsible.

BTW, thanks for this link as well Brownms46. Very informative.

http://www.calnurse.org/102103/teamissues.html

[nurseunderwater]

If she couldn't be everywhere, she shouldn't have accepted the assignment! What happened all of sudden to the "the RN is utimately responsible"??? Is that just for status, or does it mean anything when the crap really hits the fan??

huray!!! :balloons:

this is just a shinig example of a double standard.......

[Tweety, BSN, RN]

I agree with you. But if the regulations state otherwise, it probably doesn't matter. What's going to happen if you're called before the BON or sued by the family?

Are you going to argue that the law/regulations don't apply to you and that it's not your responsibility when the law says it is? Not a good idea.

If Brownms46's link is any indication, it's going to fall on the RN no matter what.

http://www.calnurse.org/102103/teamissues.html

Yes, I know the RN is responsible for ALL outcomes regardless. As an RN, I know this very well. My agrument is about the nature of the punishment or discipline involved. Should they be equal. I argue no. With the condition that the assignment was appropriate to the skill levels. LPNs have licenses and a nurse practice act themselves. They are required to report to the RN.

I realize I am responsible for the errors of the staff I'm in charge of. However, you kill a patient and we both go to the state board, I shouldn't necessarily be fired and loose my license along with the LPN.

I don't have enough evidence, but from what I've seen in real world situations many RNs aren't loosing their jobs and licenses over the errors of LPNs........unless they've forced an unsafe assignment on the LPN, unless the LPN has reported a change in condition to the RN.

In the original posters post, the LPN neglected her patient and acted independently what I can only presume was a routine and safe assignment. Had she said to the RN, "I'm so busy I can't check on my patients", or "that patient is having orthostatic hypotension when he gets up", or any other scenerio then the RN should have a greater "punishment" or be fired. But if that RN had no idea the LPN was not checking on her patients, then that's not 100% the RN's fault, in my opinion.

[jkaee]

If Brownms46's link is any indication, it's going to fall on the RN no matter what. There goes your license, because the law says your responsible for the LVN.

And, the hospital may be even more liable (or, at least, not look very good) for not firing the RN, if the law says she's ultimately responsible.

BTW, thanks for this link as well Brownms46. Very informative.

http://www.calnurse.org/102103/teamissues.html

This site was very informative, and a real eye opener too. If that is the case in all states, then I can see why some hospitals in my area are no longer hiring LPN's (NOT bashing LPN's...just taking a legal viewpoint here). I don't do hospital work, but it makes me think about the legal ramifications that could occur in the situation I presented in my first post. Where I work now is much better staffing wise, so it's not really an issue for me anymore, but all LTC/subacute RN's should be more aware of this potential issue because we deal with such a large patient load. Who knew way back when we were in nursing school that we would have to be worrying about this kind of stuff?

[Tweety, BSN, RN]

huray!!! :balloons:

this is just a shinig example of a double standard.......

It's also a double standard when the **** it's the fan the LPN claims "it's the RN's fault I'm only an LPN". But the rest of the time it's "leave me alone, I know what I'm doing". :chair:

[nurseunderwater]

It's also a double standard when the **** it's the fan the LPN claims "it's the RN's fault I'm only an LPN". But the rest of the time it's "leave me alone, I know what I'm doing". :chair:

For some Tweety this may be true, not for all.....

And we all know where that discussion leads... :uhoh21:

another example of the need for a "clearer" more standardized scope of practice for "us" LPN's.....

[Tweety, BSN, RN]

For some Tweety this may be true, not for all.....

And we all know where that discussion leads... :uhoh21:

another example of the need for a "clearer" more standardized scope of practice for "us" LPN's.....

Yes, let's not go down that road. Just wanted to note the double standard runs both ways, for some, but not all. I mean that matter of factly and not maliciously. Agree with your last statement as well. :)

[Sheri257]

I realize I am responsible for the errors of the staff I'm in charge of. However, you kill a patient and we both go to the state board, I shouldn't necessarily be fired and loose my license along with the LPN.

I don't have enough evidence, but from what I've seen in real world situations many RNs aren't loosing their jobs and licenses over the errors of LPNs........unless they've forced an unsafe assignment on the LPN, unless the LPN has reported a change in condition to the RN.

I do understand your argument. But I wouldn't count on it. I've been involved in four lawsuits both in state and federal court. If you even try to tell a judge you're not responsible, and law says you are, good luck. Game over, IMHO. I wouldn't want to even try to make that case. You're essentially counting on discretion that even the most sympathetic authorities probably can't provide, even if they wanted to, under the law.

I realize these kinds of cases don't happen every day and that it's rare. But all it takes is one bad case to ruin a career. The family is going to want to blame someone and, it sounds like they have a great case in this particular instance.

All I can say is that I'm glad to have learned this information and will definitely keep it in mind for the future.

[BBFRN, BSN, PhD]

http://www.kentucky-nurses.org/AssignmentObjectionForm2003.htm

Here's a link to a copy of an Assignment Under Protest form for anyone who's interested. This may come in handy for those who don't work in unionized facilities that don't supply the form.

[amoymak]

I'm talking about the way things are at the hospital I work at.... I just don't understand why they can't have patients and be responsible for them. Why can't their charting be sufficient... Why must and RN chart behind them, which means the RN must go in an access that patient also... Most of the charge nurses on our floor refuse to assign pts to the LPNs and just have them pass medications... I just don't understand why one license seems to be more important that another...

And Symmy whatever.. Im not even gonna argue with you... That comment is barely worth recongnizing.

it's not that one license seems more important than another, lpn's are not allowed to assess so an RN must either chart the assessment or initial the one performed by then LPN. an lpn cannot perform IVP meds so if she has a pt who requires that- an RN must do it. i can go on and on about the limitations but at the end of the day, it's not the

lpn's fault- she's practicing within her scope. maybe hospitals shouldn't hire LPN's . Keep in mind that most LPN's working in hospitals are probably quite capable of performing some of these skills that are "out of their scope".