Ethical dilemma with DON


I recently found myself in an extremely uncomfortable and infuriating situation. I work in a SNF as acting wound care nurse. During my weekly rounds, I noticed a patient with a chronic but stable wound suddenly had worsening of the wound (increased size, purulent drainage, redness, odor). I realized the dressing he had in place was dated for 3 days prior, this is a dressing that should be changed daily. So for 2 days, the nurses did not complete his wound care, leading to worsening of the wound (which constitutes neglect and potentially abuse). I investigated, gathered evidence, then reported the incident to my DON per protocol. My DONs reaction was to suggest to me that I "don't tell the nurse practioner that our nurses didn't do the dressings changes, just tell her the wound is worse but don't say why". I was shocked, and refused, and proceeded to update the nurse practioner on the situation. I could not believe my DON encouraged me to withhold vital information. My question is how severe is this? Does this warrant me reporting the incident and subsequent conversation to someone above her? How far should I take this? Or should I talk to her one on one first and give her a chance to apologize for her response? Also I'm concerned that the nurses involved causing the harm will not be investigated and disciplined accordingly. My DON doesn't seem to share my same concern for the seriousness of this situation.

canoehead, BSN, RN

6,837 Posts

Specializes in ER. Has 30 years experience.

I would give ALL the information to the NP, and tell the DON that's how you practice. I'd also tell the NP that you were advised to withhold information. I'm not sure who you'd report up to about the DON. My feeling is that you'd need several instances before reporting to the state, and that your job would be on the line when you did so. If your boss is not the DON, maybe talk the situation over with them.


17 Posts

That's one of my concerns is retaliation. I report directly to my DON and have to work with her on a daily basis. Thanks for your input.

Specializes in critical care, ER,ICU, CVSURG, CCU.

Ok, as an formerDON, I'd want incident reports.....

Anyone can notify CMS and or ombudsman

When I deemed or preceivedharm......extensive investigation by me.... Great opportunity for teaching tool and Inservice,

Daisy Joyce

264 Posts

Here's the thing--the DON definitely needs to follow up on this event, whether it's a need for re education, or a write up or what have you. She mustn't sit on this.

Why doesn't she want the NP to know? Is there drama between them? Is the NP threatening to the DON?

I'm trying to be fair, trying (and failing) to think of a valid reason the NP doesn't need to know. But the DON is responsible for the employees under her, that they do their jobs.

Is the DON protecting a particular nurse?

Bottom line is, we're at work to care for patients. Their needs come first, before our egos and feelings and stuff.

Green Tea, RN

138 Posts

So did you report the nurse practitioner that the dressing had not been changed for three days after all?


17 Posts

I did. She needed to know in order to provide appropriate care.


17 Posts

I think she reacted this way because last year we got cited on 11 different wound issues. So she's trying to protect the facility, which shouldn't be the concern. The concern should always be the patient

TriciaJ, RN

4,295 Posts

Specializes in Psych, Corrections, Med-Surg, Ambulatory. Has 42 years experience.

If this is a SNF I wouldn't assume the nurses were being negligent. It's probably extremely short-staffed and the DON knows this. She's not protecting individual nurses; she's protecting the facility and her own employment status.

Please do not compromise your ethics for fear of retaliation. You absolutely should inform the NP of your findings. If the DON retaliates you have recourse. If you are later found to be complicit with a poor standard of care you will have a hard time defending yourself to the Board or to plaintiffs.

This really smells like a staffing issue. The facility is receiving funds to provide a certain level of care. They need to start providing it.


17 Posts

Actually the staffing is overall pretty good. Our ratios are better than most. On this particular unit there was one nurse, one RT and two CNAs for 10 long term care vent patients. It really was nurse neglect. The nurses have since admitted to signing out the treatments and not actually doing them, and there were no reprocussions.