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?

[larrytyrer]

It seems like you literally did as much as you could. The advice I have for you has been stated before me: make sure you documented. If your concern is for your license, always ensure that your actions are legally defensible. Ultimately, the powers that be will have to consider what another competent nurse would have done in your situation. Administering O2 and speaking with your supervisor and on-call MD - sounds reasonable and competent. However, if you didn't document it, you didn't do it.

You followed your chain of command, and the decisions that were made were done so as a collective force. Certainly review the comments about proper O2 administration. There certainly were some issues with the handling of this situation, but as it pertains to your license, I think you have nothing to worry about.

[kbrn2002, ADN, RN]

While you understandably feel badly about what happened you are not at fault, nor is your license at risk. You informed the supervising RN and an on call MD who both declined to send this resident out. You administered the ordered neb tx, and documented that as a late entry. Sending her in after an MD said not to was following the MD order, if you had sent her after that without a really fast decline in condition you would have probably been in trouble for going against what both your supervisor and a physician said.

What strikes me though is an entire other shift also declined to send her to the ER, so how is it all your fault that two shifts worth of RN supervisors and on call MD's made the decision to not send her out?

As long as you documented thoroughly I can't see any possible reason you would be on the hook for neglect as far as any state would be concerned, but if your employer is that willing to throw you under the bus your job might be on the line. I sincerely hope not as if there is any fault here it falls on the RN that refused to acknowledge your concerns and the MD that refused to send her in initially, followed by an entire shift that didn't follow up when her condition didn't improve.

[TheCommuter, BSN, RN]

By the way, I want to reiterate that it is very difficult to lose a nursing license. Many nurses who have made egregious mistakes and/or done something that resulted in patient demise are still practicing with their licensure intact.

Most nursing licensure revocation arises from impaired practice, theft, narcotic diversion, intemperate alcohol/drug use, prescription pill abuse, and problematic issues related to addiction. It is rare to lose one's license over patient care mistakes.

[CapeCodMermaid, RN]

Everyone is responsible for their own practice so you can't say 'the RN told me.....'. I've had to argue with doctors before about sending residents to the hospital. I'm the one there..I'm the one assessing them. If it's an emergency I send them out and then inform the MD that I sent them.

Keeping residents in the facility isn't all about the money. We send far too many people out because the families sometimes think the hospital can fix grandma. They come back in worse shape than when they left.

[HeySis, BSN, RN]

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

And your patient may have been feeling anxious because she was already heading in the direction of lower O2 higher CO2.... the numbers on the monitors take time to catch up with what's really happening.

I put her on 5L of 02 via non-rebreather mask and called my RN supervisor

Some have already pointed out the liters of O2 with a non-rebreather.... but your RN supervisor should have come immediately, she should have known that the Liters were too low and done a through assessment at that time if for no other reason.

said DNR and told me that means we don't send her to the hospital. I firmly told her that is not true

You are correct! A DNR does not mean do not treat, to many people have that thought... Your patient should still be treated for her low O2 and high CO2 saturations.

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.

I hope you documented everything well. I'm not sure about your facility, but most will have some sort of policy leeway with STAT orders and when they are signed out. I hope even if you signed them out later, you documented the correct time you gave them.

I feel like LPNs can't legally assess

LPN's can and do assess, as you were doing that night. But when you noticed a change in condition the RN had a responsibility to go in and lay eyes, hands and ears on that patient. RN's delegate stable patients to LPN's within their scope... once a patient is not stable, they have to step back in and delegation still means they are responsible.

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.

It would be illegal to transfer without an MD order. It's called dumping. Patient dumping violates the federal Emergency Medical Treatment and Active Labor Act (EMTALA). The family could call and have 911 show up, but as a nurse we are expected to go through the correct channels. I'd look up EMTALA before you meet with someone so you are informed. http://www.calhospital.org/sites/main/files/file-attachments/emtala_2012_web_preview.pdf

The following is not a criticism that you "missed something" we all do the best we can with what we know. And I think we have all learned the hard way a thing or two. Things to know for the future that can protect you and maybe get results you need: You could have contacted your medical director and had him speak directly to the on call MD or take over the case. You could have gone up the ladder above your RN supervisor and contacted your DON at home. Neither of these things may have changed what happened but you would have been able to document that you continued to raise your concerns.

[SaltySarcasticSally, LPN, RN]

I actually had a somewhat similar experience in my first 6 months working as an LPN. We were a standard LTC with a few rehab beds thrown in, regularly took in those who were 40's/50's either hooked on drugs or withdrawing but yet we had no extra training or materials to meet their needs. We were a LTC facility not a detox unit. We had a resident come in who a few hours later became very lethargic and could not focus. I obviously did not the patient's true baseline but the patient had come in talking so to be nonresponsive all of the sudden was obviously worrisome. Patient was a full code, I took vitals, BP down, HR up, called my DON and MD, all of whom said to not send out for the very same reason that census was low and already tight on money. It felt totally wrong and was ringing every alarm bell in my body. Patient started to seize 30 minutes later, we had zero standing orders to treat it. I called 911 and got the patient out of there and took the heat from administration. Patient coded in the ambulance but survived. I did the right thing and I left the facility a few short weeks later.

If you documented your phone call with the MD and the nurse supervisor, you will be just fine, do not fret. But I would however get your resume ready and start looking, the facilities unwilling to send patients to the hospital because of the money aspect are the scariest places to work in my opinion.

[Msmedic68w, MSN, RN]

I hope you TORB'd the order that the doc gave you to cover yourself and documented accordingly. At worst, you could get in trouble for the O2, oxygen is technically an order. And the fact that you only gave her 5 via NBM could be a problem. Obviously, if somebody needs air you're not going to deny them, but make sure you always get an order for the 02 once it has been initiated (unless they have an order stating to do otherwise).. The MD would have told you to increase the O2 for sure. Always make sure you see any DNR for yourself, I'd never take anyone's word for it.

[Glycerine82, LPN]

Even if the resident was a full code, it doesn't matter because they didn't code. You're right in that DNR doesn't mean don't transfer, and if they made the decision not to send her it shouldn't have been based on her being a DNR, anyways.

[jschut, BSN, RN]

I do not believe you will lose your license over this, but in the future, document, document, document!!!!! Note that "So and So" RN was informed and at what time, note that you requested of supervisor "Whatshername" information and what to do and the time. Note that you called Dr "whoever" and his response and the time. Cover your a**, cause no one else will do it for you!

[Esme12, ASN, BSN, RN]

MODERATOR NOTE:

As per the Terms of Service we cannot offer legal advice.

OP if you have malpractice insurance give them a call. Documentation is everything. Without knowing more it is impossible to say what is right or wrong.

I caution you if there is going to be "issues" about this patient. While allnurses is anonymous...it is public and can be seen or googled by anyone and can be subpoenaed.

[SunnyPupRN]

I think you advocated well in your scope of practice as an LPN. The only thing I would be cautious of is that if anyone is going to be thrown under the bus, it would probably be you. If they come to you with papers to sign regarding the incident, I would politely but firmly decline to sign anything, but that's me. Are you carrying malpractice insurance? Maybe call your insurance and let them know what happened.

[futurenaijaRN, BSN, RN]

Is so sad that most of big health care facilities just care about their money and not their patients. I had a similar experience on two different occasions where pts needed to be sent out, but the nurse supervisor and doctor refused to send them out, I advocated for these pts to be sent out, but being just an ordinary CNA in finally year of nursing school, no one listened to me. The next morning right after the end of my shift, one of the pts passed on. I cried my heart out. The other pt fell and hit her head, few hours later she started having raccoon eyes, but they still refused to send her out. I quit my job that night, and I pray the lady is ok.