SCENE SET-UP: Unit 1 = 60 Residents, 2 LPNs, 1 RN, 4 CNAs. Split into two halls..
TIME: 10:30pm (30 minutes before shift change)
RN setting at desk,
LPN #1 charting restocking cart,
LPN #2 on phone with Pharmacy trying to get pain meds (that were supposed to be delivered 6 hours ago) for new admit. (Been playing phone tag with Dr. Pharm most of the evening) Family present and very upset.
CNAs doing last dry round
CNAs for LPN #2 come and say LPN #2, Resident X has fallen of the bed and hit her head. RN and LPN #1 go to evaluate Res. X, because LPN #2 is on the phone.
RN and LPN #1 agree Res. has to be sent out, due to hitting head. (LPN #2 still on phone) RN calls EMS and does paperwork to send to E.R. with asisstance from LPN #1. 10:45 EMS arrives, (LPN #2 still talking with pharmacy trying to get pain meds.) RN handles the transfer, gives EMS report etc. Res. leaves the building.
11pm CNAs, RN and LPN #1 go home. LPN #2 hangs up with pharmacy at 11:10, her whole crew had left, she leaves at 12:30 because she due to being behind because she had been trying all evening to get pain meds for new admit.
3am Res returns from ER diagnosis UTI !!!!! Res. didn't even have head looked at... No one called report to hospital, prior to transport!
8am family showed up and is not happy that a c/t scan wasn't done at hospital, ADON goes to look at nurses note just to see what happened, and nothing was documented anywhere. Who was at fault for this?
LPN #2? Although she was busy with another Resident, and basically had no knowledge of what happened, other then something happened, although it was her Resident that got sent out.
RN ? Her role on evening shift is to asisst LPNs when they get behind, and she left without reporting to LPN #2 what had happened and what needed to be done.
according to the ADON, to appease the family, someone has to be fired! Who would you fire? RN or LPN #2 or both?
I'll tell you the outcome after I get a few opinions...
