Neglect...LPN was fired, RN was not

[KacyLynnRN]

I wanted to get everyone's opinion on a heated debate at my workplace. I work in a large hospital's Med/Surg unit. Usually 8-9 patients are lumped together as a "team" with an RN, LPN and CNA on each time. At night, it can be 12-14 patients, often with only an RN and LPN. Usually you 'split' the team with the LPN taking some patients, the RN taking some patients, and each person doing total care for their patients. One night about a month ago, an RN and LPN had 'split' their team. One of the LPN's patients was found dead on the floor at about 5am, they called a code but he had been dead awhile and rigor mortis had already set in. The patients was in his 60's and a GI bleeder, he was being prepped for a colonoscopy the following morning. I heard through the grapevine the hospital had done an autopsy and the patient had fell on the floor, hit his head, and died as a result. He had been dead about 3-4 hours before he was found. As a result of this, the LPN who was responsible for this patient was fired. The RN on the team recieved a verbal warning, but otherwise she was not disciplined. A lot of people at our work complained to our manager, and she said the LPN has a license too, and therefore she is legally responsible for her patients just like the RN is. I am an LPN but am also a full-time RN student and will graduate in 11 months with my RN. The LPN's at work have been bad-mouthing the RN and our manager, saying that the RN is over the LPN, and she should have been fired too. I personally agree with our manager...I feel that while I am not an RN, I am an Licensed nurse and with that comes personal responsibility for my nursing actions. A lot of my LPN peers disagree, so I have kept my opinion to myself for fear of my coworker's backlash. It is really a HOT topic at work now. What do you all think?? Am I right in my opinion?

[NursesRmofun, ASN, RN]

just a student with a question.... is it legal to use just lpns (no rn on staff at all) in any facility? or does at least 1 rn have to be on staff for the "license and delegation" stuff. could a Doctor or NP be used or just strictly an RN? Just wondering because I remember working at assisted living and the Rn was only in the building 1 day per week. Judging by the responses here that seems like a huge liability for her if something were to go wrong. I too have heard RNs refer to the lpns "working under my license" and just wondered if that is the only way and lpn can work or can they work without an RN on the payroll?

It depends on what kind of facility and what state, I'd say. In NY, a LPN can be alone in a LTC facility at times and under certain circumstances. An RN needs to be present 8 hrs. of the day in a LTC facility, and LPNs can be alone there if a RN can be reached by phone during the other 16 hrs.....that's my understanding. To my knowledge, a RN always has to be present in the hospital.

[smk1, LPN]

It depends on what kind of facility and what state, I'd say. In NY, a LPN can be alone in a LTC facility at times and under certain circumstances. An RN needs to be present 8 hrs. of the day in a LTC facility, and LPNs can be alone there if a RN can be reached by phone during the other 16 hrs.....that's my understanding. To my knowledge, a RN always has to be present in the hospital.

ok one more question... how do you know who is the RN who is "responsible" for lack of a better word for the lpn's actions? In a hospital would it be the charge nurse or NM or would you find out at trhe beginning of each shift who was "assigned" to oversee the lpn?

[KacyLynnRN]

Wow! I am shocked how many people responded to my thread. A few more detalis on the situation...from what I heard at work, it was a crazy night that night and only 6 licensed people for 37 patients. Sadly, this seems to be the norm at my hospital. I am surprised how many people posted and said they are shocked at this staffing ratio. I have only been an LPN for 1 1/2 years, all at this hospital on this unit, and that is the only thing I've ever known. 12-14 patients to an RN and LPN on night shift, I was on night shift for 8 months and finally told my boss I was gonna have a nervous breakdown if I had to stay on nights, after a particularly bad night when one pt.'s BS was 31 and another pt. was having severe chest pain and yet another patient was kicking at us and threw his bedside table at the window and threatened to kill us...ALL at the same time! I couldn't take it anymore. Now I am on day shift with 8-9 patients for RN and LPN. Hectic and crazy but at least I feel like there's a better chance I won't find someone dead on the floor hours later on day shift. I know this staffing is horrible and dangerous at best, but from what I hear from friends that work in other facilities, it's the same way everywhere.

Anyway, back to the original delimma...the LPN told our boss that it was a crazy night and a lot of things were going on with other patients, they got an admit, etc. and she just couldn't get in to check the pt. RN says that she thought the LPN checked him. In my opinion, I had worked with this LPN quite a bit, she could be a little lazy at times with chit chatting with people, etc. but for the most part seemed to be a good nurse. The LPN has been fired but she is now working for a local nursing agency doing temp work. No other punishment as far as I've heard. Granted this only happened 2 months ago. RN got a written/verbal warning and nothing else.

What makes me sad is that this horrible incident has changed nothing at work. Still the same unsafe staffing ratios every day. I guess it's easier for them to blame someone else then take a long hard look at their greedy selves!

[Tweety, BSN, RN]

What makes me sad is that this horrible incident has changed nothing at work. Still the same unsafe staffing ratios every day. I guess it's easier for them to blame someone else then take a long hard look at their greedy selves!

That somes it up very well. They'll fry the nurse, blame the nurse, and that's about it. And a good nurse bites the dust. Sadly the ratios you mention are the only norm I've seen in 12 years at this institution, it's quite common from nurses on nights to go 6 to 8 to one (meaning of course and RN/LPN combination = 12 to 16).

As was noted by the nurse practice act the RN is ultimately responsible for this outcome. If the LPN reported to her the problems with her assignment, and she should have as it sounds like there were issues that needed RN attention, and the RN did nothing to help, then the RN is more negligant and this puts a new spin on how I feel. It definately sounds like a lack of communication if the RN thought the LPN checked on the patient when she didn't. Here's where ongoing assessment of the outcomes of the delegation process comes in. I'm getting a headache now. :)

[Brownms46]

That somes it up very well. They'll fry the nurse, blame the nurse, and that's about it. And a good nurse bites the dust. Sadly the ratios you mention are the only norm I've seen in 12 years at this institution, it's quite common from nurses on nights to go 6 to 8 to one (meaning of course and RN/LPN combination = 12 to 16).

As was noted by the nurse practice act the RN is ultimately responsible for this outcome. If the LPN reported to her the problems with her assignment, and she should have as it sounds like there were issues that needed RN attention, and the RN did nothing to help, then the RN is more negligant and this puts a new spin on how I feel. It definately sounds like a lack of communication if the RN thought the LPN checked on the patient when she didn't. Here's were ongoing assessment of the outcomes of the delegation process comes in. I'm getting a headache now. :)

Sorry about your headache Tweety...but I agree with you:)!

[Tweety, BSN, RN]

ok one more question... how do you know who is the RN who is "responsible" for lack of a better word for the lpn's actions? In a hospital would it be the charge nurse or NM or would you find out at trhe beginning of each shift who was "assigned" to oversee the lpn?

We usually have one or two LPNs on my shift and it's understood that the charge nurse, myself, is assigned to the LPNs. I get report from the offgoing charge nurse on the entire floor, and often I don't have a patient assignment, so it's o.k. But when I do have a patient assignment it gets a little scarey as I have to trust that the patient assignment that the LPNs have is being handled safely and appropriately. But I've drilled into both the LPNs and the RNs I work with to constantly update me, and I constantly check on them as well. Once on another unit I realized it was me and five, yes five LPNs and no other RN. Stupid me, I was responsible for 30 patients that night, and didn't think about it until it was too late. Whew.....

Other shifts on the assignment board next to the LPNs assignment the RN responsible is made known and it isn't always the charge nurse.

The LPN should always know who the RN they report to is, and of course the RN they are reporting to should no at the beginning that the LPN is in their assignment.

We don't do team nursing where I work.

[Tweety, BSN, RN]

You're exactly correct, as to the purpose of this thread...was should the RN have been fired. And I can't blame...nor do I, your not wanting to take heat for someone who should be competent enough to do the assignment delegated.

I'm glad to know that you have no problems working with LPNs, and I don't blame you for fighting the unfairness that comes with your position. I realize it's an awkward...and stressful position. You shouldn't have to worry ability of someone whom you have no choice in working with. I know that having such a responsibility would make me nervous, and very cautious.

I recently started a new contract....and I have been lucky enough to work with an RN who also willing to work with LPNs. In fact on the whole unit, I have seen no conflicts between RN, LPNs, or CNAs. I feel lucky to be on a unit, where I am not only wanted, but treated with respect.

I have great respect for all those I have worked with on this unit. I told the RN and the NM, that if I was to have hand picked her, I couldn't have picked a better partner to be with! I know my assignment will be fair...and that she has my slack...and I her's. But I seriously doubt if she ever has any slack, as she is very much on the ball:)!

This RN constantly supervised the assignment she had delegated to me, and as she saw that I could handle things, she backed off. But she still maintained her supervision. She didn't just walk away....and only check on her pts. And I didn't mind one little bit...that she was checking on things, as I understand her need to know, that what is supposed to be done, is being done....correctly. For she felt obligated to ensure the quality of care that all of the pts. assigned to us received. (Which by the way was only 7, and one had a sitter.) We both ran all night....but we ran together!

She, you and other RNs who work with LPNs, and CNAs as a team....to me are the best ways for safe care in the understaffing, and shortage of RNs. It is units like this, that brings back the joy of working on the floors. Too bad that all aren't like this. Too bad there are RNs, LPNs, CNAs...RT's...MAs...etc...etc, who believe they can just do the bare min....or take too many shortcuts...push their responsibilities off on someone else...and expect to have no ill effects to come out of it.

Shame on them....and shame on a system...that allows them to bring harm to their pts, and/or their team members...because they are allowed to practice...for the want of a warm body sometimes.

Excellent post! The bottom line for me is TEAMWORK and knowing exactly what your duties and expectations are. That and COMMUNICATING! I'm glad you've found an environment like that.

[tiona]

I kind of feel this way as well. I don't think on night shift 12 to 14 patients is necessarily unusual, even if one of them is a GI bleed. GI bleeds are on med-surg floors all the time. On our floor they are usually on telemetry, but mixed in with a six patient assignment. We don't do teams, but the RN covering the LPN has a full load as well. I delegate that assignment to you, you have proven competency or you wouldn't be working there. I might make one round eyeballing the patient, but if you don't check on the patient for four hours, I shouldn't be fired.

I understand all that you are saying Brownms46, but I disagree. The RN should not have been fired. Yes, according to the Nurse Practice Act the RN is responsible for every action the LPN does, mistakes and all. However, if I delegate a safe assignment to you, and six to seven med-surg patients is a safe night shift assignment (sometimes) IMOH (mind you we might use LPNs differely here than you do there), and you mess up, and it's not proven I knew about it, or knew you were incompetent to handle it, I shouldn't be fired for your neglect. Disciplined in some fashion, but not fired. Unless she had some knowledge those patients weren't being taken care of, or rounded on q2h or whatever the standard is, then it's not her fault the LPN was not doing her delegated assignment.

I've supervised many nurses, both RNs and LPNs and CNAs who have made errors, who were lazy or incompetent in one way or another. I'd hate to think I deserved to be responsible for all of that. I'd quit and find an all RN place to work if that were the reality.

I agree comletely. If the LVN was hired by the facility she/he must have been considered competent. LVN's want to be respected and considered "real" nurses. We need to be responsible for our own actions. The RN should not be fired. On a med/surg floor vitals are suppose to be taken q4. Gimme a break...the LVN and CNA were in the break room or something. How hard is it to peer into a patients room? A patient on the floor really should have been noticed. At least if he were in bed one could argue that he appeared to be sleeping peacefully.

[jkaee]

It depends on what kind of facility and what state, I'd say. In NY, a LPN can be alone in a LTC facility at times and under certain circumstances. An RN needs to be present 8 hrs. of the day in a LTC facility, and LPNs can be alone there if a RN can be reached by phone during the other 16 hrs.....that's my understanding. To my knowledge, a RN always has to be present in the hospital.

In PA where I live, an RN has to be present at all times in a LTC facility...LPN's just were given the "priviledge" of taking verbal orders from the doctor here in PA, so I don't know if that will change anything, but I don't forsee LTC or subacute facilities not having an RN on at all times.

[Brownms46]

Have you actually worked nites on med-surg??? And since when is a pt. on a med-surg supposed to have VS taken Q 4hrs??? Are you a "real" nurse???

[tiona]

Have you actually worked nites on med-surg??? And since when is a pt. on a med-surg supposed to have VS taken Q 4hrs??? Are you a "real" nurse???

Yup, I'm "real." In CA vitals are taken Q4h on med/surg floors. Even at night. For a patient with a GI bleed or some other condition putting them at risk for shock, vitals are often ordered evey hour. If I read the original post correctly there was an RN, LVN and CNA on board. Isn't it a reasonable expectaion to at least look at the patient every hour? A patient on the floor long dead seems pretty inexusable to me. I stand by my original opinion. The LVN is responsible. I'm an LVN, BTW.

[susanmary]

Have you actually worked nites on med-surg??? And since when is a pt. on a med-surg supposed to have VS taken Q 4hrs??? Are you a "real" nurse???

I've worked nites on med-surg. Not counting post-op vital signs, frequent vs for blood transfusions, etc. -- vitals were q4hrs. Honestly. And I'm a "real" nurse.

After rereading the posts, I agree that the RN should not have been fired. Hopefully, in her new position, the LPN will check more frequently on her patients.