Could I be sued for neglect or lose my license over this?

[Ccinct]

I work in a long term care facility. Last night I had a resident who has sleep apnea and is non-compliant with her bi-pap and also has a history of acute respiratory hypercapnia and hypoxia. Around 2:00a she told me she was feeling anxious so I gave her a PRN trazodone 25mg, a medication she has taken many times before. About a half hour later she became SOB so I took her SP02 and it was 70% RA. I put her on 5L of 02 via non-rebreather mask and called my RN supervisor. I am a LPN. The RN did not even go in the room to assess her because her 02 sats went up to the 90s. My supervisor just opened up her chart and pointed to the page that said DNR and told me that means we don't send her to the hospital. I firmly told her that is not true and that I want to send the patient to the hospital. By this time we had the patient on 3L via NC, her 02 sats and VS were all WNLs but she was so lethargic that she was not even verbally responsive. Her baseline is alert and oriented times 3. I called on call and asked to send her. The on call MD said no, monitor her there and get an order for PRN duo neb which I administered. I once again pleaded with the supervisor to send her and the supervisor told me no because the facility needs to save money and when we send people out it wastes money. I could not get in touch with the resident's son, her POA but at 6 am I called her brother who came to visit. At 7am a new supervisor came on who also just wanted to keep the resident at the facility and monitor her there despite the fact that she was still not verbally responsive. At 3p, the new shift came in and they finally sent her out. The called me to say that I needed to come in and write a statement. They told me that the hospital had intubated her and that I should have called 911 even though the MD and my supervisor told me not to. I also found out that the page in the resident's chart was wrong and that she was actually a full code. The other thing that I am worried about is that I signed out the Duo neb tx and the trazodone late (I had to sign them out as late entry) because I didn't have time to put them in the EMAR with all that was going on.

On the one hand I feel like LPNs can't legally assess and I was just listening to the RN and the MD who told me she was fine and to monitor her at the facility. On the other hand I am worried that the state will hold me accountable and I will potentially get sued for neglect. Does anyone have any advice for me?

[indish]

And if you had called 911 they would say you were insubordinate and call you in the office for that. I would think if you are practicing within your scope of practice and followed all policies you have nothing to worry about. It doesn't seem your facility stands behind their staff though

[CrunchRN, ADN, RN]

Wow. Between a rock and hard place. You could not possibly win or do good no matter what action you took. And no, I don't think your license is at risk.

[sallyrnrrt, ADN, RN]

I agree with above posters, FYI, the Fi02 or liter flow for a non rebreather mask should be nearer 10L/min..... But that has nothing to do with your delima......

you out were directed by an provider an nursing supervisor......but

as as a nurse regardless of RN or LPN, if you feel, the patient needs are not being met, you advocate for more.......of course that is easier fo me as a RN and RRT........but you have every right to advocate....

[Sour Lemon]

I also found out that the page in the resident's chart was wrong and that she was actually a full code.

I have no advice, but it sounds like you were wronged in a big way and I hope that you're able to come of this unscathed.

I am curious about the "wrong" DNR order, though. In what way was it "wrong"?

[KatieMI, BSN, MSN, RN]

You did the two main things right:

1) you advocated for the patient to the very limits of what you could do, and

2) you were well within your scope of practice.

That's, basically, the point. You did what you could do, and told to do, within your limits. So no, your license is not at risk.

Now, for the future reference:

- patient with CO2 retaining tendencies can be SaO2 100% and still have CO2 through the roof, with all the results. If patient like this becomes anxious OR too sleepy, the first step must be set of vitals including SaO2. The second step must be that BiPap machine, because these patients cannot exhale all that CO2 on their own. Oxygen is good but even 100% O2 doesn't do anything with the fact that the patient cannot EXHALE CO2 effectively enough.

- never, ever give such patients anything "for anxiety" or "for pain" (save for Tylenol or NSAIDs) till you know they are OK breathing. Doesn't matter what, don't do it. Even if the patient was taking these meds every 4 hours for the last 20 years.

- "anxiety" meds can be given to the patient to make him/her more compliant with the said dreaded BiPap

Simple enough:yes:

I really hope your biggest trouble would be those meds you signed off "too late" (hugs)

[Ccinct]

There was a page in the patient's chart that said DNR/DNI and nothing else. Usually we just look at that one page because it's a quick way to find someone's code status instead of reading their whole advanced directives form. That was the page that the supervisor opened up to and showed me and I never questioned it until the resident's brother came in and told me that she was a full code. Then I went back and looked at the full advanced directives form and she was indeed a full code. There was a new supervisor on at the time and a new nurse (it was after 7a) so i had the new nurse bring it into the new supervisor who was arguing with the patient's brother about it. The new supervisor told the new nurse, "oh well that's not relevant."

I feel sick to my stomach still. I knew in my heart what I should have done and I feel like I was too chicken **** to do it. I always second guess myself and this time there was big consequences.

I have stupid bad anxiety and I know that no-one is a fortune teller but if anybody has some kind of educated guess about what will probably happen please let me know.

[crazin01]

Wow..

I think your license (and I don't know who would sue you, if anything they'd go after the facility) is not in risk of anything. I would make sure you have it documented in the patients chart/computer, whatever, that you communicated issue to supervisor, and MD on call. I think it sounds like you did everything you could do.

I'm curious if she's back to her baseline mental status/will be once she's extubated. You had said she's normally A&Ox3 as a baseline. The fact she was no longer verbally responsive later in the shift should have concerned your supervisor/MD that something not good happened.

I think you'll be fine, as long as your documentation is done. This is why we're told to CYA in nursing school.

Best of luck... :-)

[TheCommuter, BSN, RN]

You were directed by the attending physician via a telephone conversation to NOT send the resident to the hospital ER.

As long as you documented your observations, interventions, and conversations with the physician and supervisor, you should be fine. You did what a prudent LPN would do in a difficult no-win situation.

[AnnieOaklyRN, BSN, RN, EMT-P]

Please do not put someone on a non-rebreather at 5 LPM, you are actually giving them less oxygen than is in the atmosphere! A non-rebreather needs to be at at least 10 LPM of oxygen.

Please review oxygen delivery devices.

Also I hope you documented all of this, as it sounded like you wanted to send her out and it sounds like she was lethargic secondary to hypercarbia.

Annie

[rescueninja1987]

As long as you documented well, you will be just fine. The only thing I would say, which has already been stated, is make sure your non-rebreather is on at least 10L/min or more (and make sure it isn't hooked up to a humidifier!). On another note, I think it's awful that a facility would refuse to send a sick patient to the hospital in an effort to line their pockets, but I guess that's another discussion entirely.

[DeeAngel]

The only person who can truly answer your question with accuracy is an attorney specializing in nurse legal issues.