CNA forgot to take patient off bedpan for 4 hours and now patient has wounds

[rork17]

Title pretty much says it all. A cna left a patient on the bedpan for 4 hours and now the patient has 3 open areas on their buttock. Obviously it is documented, assessed yadda yadda. This is a good cna how much trouble do you think they will get into? I havent had a situation like this before.

[bsyrn, ASN, RN]

Just my 2 cents, why wasn't a call bell placed in reach of the patient?

[Kooky Korky, BSN, RN]

On 8/14/2019 at 3:48 PM, humerusRN said:

IMO, 4 hours without the RN rounding is inexcusable and definitely would be grounds for disciplinary action for the RN (and the CNA).

Nurse might have rounded but not noticed that the pt was on the pan. That is, nurse was rounding for meds, IV, O2, splints present, H20, remote, kleenex, trash can, call light within reach or some reason other than looking to see if the pt was on the pan.

If the pt and pan were covered, the nurse would not necessarily have noticed the pan.

On hourly rounds, I did not really think to see if a pan was under the pt. I wanted to see my pt breathing, check on IV's and O2, maybe I gave meds. I guess I will be checking for bedpans from now on.

Are you saying that you look for bedpans in use every time you round?

And I still think the DON, Educator, Admin and everyone else above that RN is liable. I'd bet my tookas, as the commercial says, that no one ever taught the RN to look for a bedpan.

[Crash_Cart]

Quite frankly, I am at a loss to understand how anyone can put a patient on a bedpan and somehow just "forget" about it.

I don't think I could "forget" about it even if I wanted to... There must be some kind of built in bed pan alarm system inside my head. ?

[Kooky Korky, BSN, RN]

On 9/11/2019 at 1:11 PM, bsyrn said:

Just my 2 cents, why wasn't a call bell placed in reach of the patient?

Perhaps the pt was unable to use it?

[Daisy Joyce]

On 9/13/2019 at 1:55 AM, Crash_Cart said:

Quite frankly, I am at a loss to understand how anyone can put a patient on a bedpan and somehow just "forget" about it. 

Unlikely, but not impossible.

I can imagine a scenario where the CNA *usually* stays in the room while the patient is doing their business, but in this case gets called away, the spit hits the fan (somebody falls and hits their head, another resident starts having behaviors), things escalate and the bedpan gets forgotten, especially if the bedpan person is confused and forgot to ring for somebody to take them off.

Especially because it sounds like the CNA has a good reputation.

[MSO4foru, ADN]

For a brief time I worked LTC on days. All I really knew if pts were breathing or not. I had 30 pts. At some point, we all need to accept that there are needs that are not going to be met by current " acceptable " ratios. We need better staffing- more for the folks we care for than for ourselves.

[rork17]

@Daisy Joyce That is essentially what happened. And as an update to the whole thing. Patient died from something brain related a week later. The butt wounds never came up in anything. The Cna has been one for 3 years and with no obvious issues. Building was running short that day. 1 nurse and 2 cnas for 25 patients. This all happened during dinner rush and a fall.

[Tristen Johnson]

Where were YOU to check on the patient in those 4 hours? Can't put all the blame on the CNA, when it is just as much as much as responsibility of the RN. Moral of the story: always check on your patients.

[JKL33]

On 10/3/2019 at 12:13 AM, rork17 said:

@Daisy Joyce That is essentially what happened. And as an update to the whole thing. Patient died from something brain related a week later. The butt wounds never came up in anything. The Cna has been one for 3 years and with no obvious issues. Building was running short that day. 1 nurse and 2 cnas for 25 patients. This all happened during dinner rush and a fall.

Right. And to all of those outraged on the thread, no fair being upset after the fact; badness is completely inevitable under the circumstances.