Neglect...LPN was fired, RN was not

MoJoeRN,C · May 4, 2004

Supervisors and administrators use the "nursing shortage" as an excuse to staff as they do. Also they are against the nurse patient acuity ratio being advocated in California for the same reason. $$$$$$

Scubadiver · May 4, 2004

12-14 patients between two nurses on a med sug floor are too many patients, even if they do not do total care. The hospital should be facing a law suit and they know it.
The nurses might or might not be wrong in not having protested the assignment prior to accepting it under protest. Personally IMHO the nurses made a poor judgement in accepting such an assignment. (You do have the power to effect change)
A GI bleeder is a very high risk patient. Putting such a patient into this kind of mix is just poor judgement.
The nurses are responsible as they accepted the assignment witout protest.
However, stuff rolls down hill. The hospital will Cover it's own backside at the expenses of the nurses'.
They will always place blame on the lowest level of caregiver first. That enables them to legally distance themselves from responsibility. Firing the LPN was a pre-emptive move to protect thier own liability.
They also cover themselves by slapping the RN's hands.
The LPN should have protested the assignment. But more important the RN should have (being an RN) used better judgement in allowing either of them to take this assignment. As an RN I would not have assigned the the GI bleeder to the LPN (I was an LPN and now am an RN) not at least witout keeping some tabs on this patient myself.
No the hospital is wrong. And the Nurses are wrong especially the RN for accepting assignments like this without protest. The RN carries > responsibility on this aspect because she (legally) has the education to recognze unsafe situations better than the LPN. (notice I said legally, this is not a putdown toward the judgement of the LPN. This is just how the BON and courts would see it, if they were to examine this aspect of the situation)
The LPN holds some responsibility for accepting unsafe assignments but the RN is the role model here. The LPN is responsible for her patients and is responsible for notifying the RN if she is overwhelmed and can't get in to check her patients frequently enough.
The hospital is wrong for it's staffing practice. However, it is the nurses that should be making judgement about that practice and effecting the needed changes. Administators do not care for patients, are not in a position to judge safe levels, are not usually even nurses. Administrations duty is to proved care at the lowest cost and greatest profit. They are resopsible for safty but the bottom line is $$$$ so if they can get away with cutting corners they will. The nurses need to become more pro active (ie get some back bone) in effecting safty. The nurses need to hold administrations toes to the flame.
As I said it rolls down hill and hospital will ALWAYS disapline the lowest level care giver first to distance themselves from responsibility.
See if they can show it was this low level person who "didn't have the education etc." of others higher up then those higher in the chain and the hospital itself are better protected. "It was that dumb girl we hired with out an RN education to help out that screwed up. We would never do that ourselves"
You fire the maid or janitor if you can place blame there. Show that management is not responsible thier only mistake was in hiring a janator who did not know that if you mix bleach and amonia that it created a lethal enviorment.
I know this sounds harsh but when it come to liability situations this is the way of the world. FAIR? ABSOLUTELY NOT. Real? Yes.
I suggest you do not partisipate in the finger pointing blame game. This is a tactic that higher management uses to distract others from the responsibility they carry.
In this case there were many level of people responsible. Everyone is trying to distract attention from themselves.
Use this as a learning tool. Learn how to be a change agent.

Where do you work that 12-14 patients between two nurses at night is too many? That's a 6-7 to one ratio. Most night nurses in a med-surg unit would give their eye teeth for that kind of assignment. The real question is... why was the patient unattended for that many hours? In defference to all the wonderful LPN's out there - THIS LPN should have been making rounds AT LEAST every two hours.

GibsRN · May 4, 2004

While the patient ratio is high I have worked in the same conditions. However, I knew my LVN skills and trusted that. If I was unfamiliar with them than I was extremely more cautious. I always made the initial rounds with them on the patients and that did routine checks. We tried our best to put the more "critical" patients closer to nurses station if at all possible -- but the LPN should have known to check these patients on a more frequent level. Should the RN have been fired? Good question. You are ultimately responsible for the patients on your care. While the LVN is a licensed individual you are duly responsible as well for the care. While it may be an unpopular IMO I think they both should have been fired.

Nurse Ratched, RN · May 4, 2004

With all due respect Agnus your GENDERED response in no way helps the poor souls who have found themselves embroiled in a s**tfight!
I am glad that I do not work with you as I would have NO HOPE of being backed up for any reason at any time as you appear to be the judge and jury!
I am an RN and I only have one more thing to say. In fact it is a direct quote from your ill informed, misguided diatribe! "I suggest you do not partisipate in the finger pointing blame game"
Nuff said.

Actually, I thought Agnus' response was a realistic view of how *administration* will tend to react in a particular situation to minimize the facility's exposure. Please re-read it and consider it from that standpoint.

To quote Agnus from the post:

FAIR? ABSOLUTELY NOT. Real? Yes.

sloydrn · May 4, 2004

Hi, I thought I would chime on this one. I have a background in administration and legal nursing.

When a tragic event such as what you described happens, the hospital is going to be worried about a negligence/wrongful death action. ie Administration has to assess whether the LPN who was responsible for the care and safety of the patient during that shift was negligent in her duties, ie did something a reasonable and prudent LPN would not have done, or failed to do something a reasonable and prudent LPN would have done. Sometimes people just up and die unexpectedly, but some of the factors the hospital will look at include: was staffing adequate for the acuity/caseload that night? If the unit was short-staffed, was the supervisor notified, when, by whom? Did the nurse(s) keep speaking up until they were heard? How long since the patient was checked? 3-4 hours may seem like a long time. Was he allowed to get OOB? What was his state of mind? confused or orientated? Was he high risk for falls? if so, what precautions were taken? Did anyone hear him fall? How often would a reasonable nurse have checked on him? Was proper action taken once the patient was found?

You also may not know if this particular LPN had any other personnel issues that may have prompted her firing. The hospital may have elected to terminate her in an attempt to mitigate the possible exposure to damages that might be claimed by the surviving family of the decedent. ie they can say they took action to prevent future events of this nature, a defensive tactic which gives them the argument (at least) that they took action after the event. Although this may seem unfair, unless the RN had direct knowledge that something was happening with that patient and chose to ignore it, the responsibility rests with the direct care provider, even though the RN "supervises" her. It would be unusual to expect the RN to check on every patient the LPN had, in addition to her assignment. Unless that is the customary practice in your facility, there was probably no breach of standard of care for the RN, as she wasn't assigned directly to that patient, even if she was 'charge' nurse. The responsibility would fall more directly to the LPN.

It is the administration's responsibility to make the hiring/firing decisions, and in Texas, there is at-will employment, so a person can be fired at any time without explanation. I would be disappointed to hear that this event causes a rift between the LPNs and RNs, as they say, the next time, it could be you that ends up smack in the middle. I would hope you can find a way to each learn from this unfortunate event, and if your staffing is inadequate, keep speaking up. That is what a reasonable practitioner would do. Initiate the chain of command when you sense something is uncomfortable for you. I hope you and your peers will find a way to continue working together and support each other, as it is not easy in the nursing front lines! Thanks for the chance to respond!

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?

Tweety, BSN, RN · May 4, 2004

Ya know, long long time ago when I was young, it was policy for q1h visual checks of each medsurg patient. We on our 'team' shared this responsibility, took a small flashlight and quietly rounded hourly on our medsurg patients to make sure out patients were OK, didn't wake them if asleep, but observed they were in bed breathing normally, etc. Guess this is no longer done anymore but might be a good idea.....if I was in charge I would sure want this done. From a liability standpoint. Finding someone on the floor cold, dead many hours is every nurses' worst nightmare.

We do the same, but it's q2h, or more if warranted. Would be nice to be able to check q1h. Heck sometimes you start with patient #1 and you're only on patient #4 an hour later and you've got two or four more to go, certainly can't go back to patient #1 without seeing the rest. I've been known to take the penlight in and eyeball the repirations and the IV site. But if something happens you might not be back for two hours, or if your busy even later than that. Hmmm....do you think safe and low patient to nurse ratios might have better outcomes for patients?

GibsRN · May 4, 2004

Third Shift Guy -

In California they were suppose to change the nurse to patient ratio - however I have yet to see that happen, at least at our facility. It's really sad for the patients and the staff. Often times our 1:1 patients become 4:1. Thank gosh I no longer work on the floor any longer. When I did, I worked night shift and I had WONDERFUL LVN's. If there was the slightest problem they notified me immediately and they had excellent assessment skills. I did not always find the same on day shift and often times they were so swamped [of course they still are since we went to computerized medical charts and medications - which I understand has created more medication errors than when we did it by hand ]

I understand about the hospital trying to protect themselves for the legalities of the issue and that there may be more to the story than most know -- but for it to create a rift between the LVNs and RNs is sad - the only ones that truly suffer are the patients.

mounceb · May 4, 2004

I too am an LPN and a full-time RN student. I work in the ER at my hospital now but put in my time on the med/surg floor here as well (over a year). We frequently do not have an Rn on the floor. The standard is to divide the patients equally if possible and everyone does everything. We do usually have at least one CNA. I frequently had to take at least 9 patients and have had as many as 12 all to my self. I am and was ALWAYS responsible for my patients. If something happens to them - I answer for it because IF we do have an RN on the floor, she has her own load and all of the pushes, blood, etc. The standard is no more than 7 per nurse, regardless of licensure, but I have sen as many as 14 to one nurse. That is way too many and yes it was wrong... but we are an 80 bed rural regional hospital and we did what we had to do. It is unsafe and our hospital offers 15,000 dollar sign on bonus for an RN for 3 years. But there is none to be had. So, I agree that the LPN was at fault. She/he should have checked the patient more often barring any severe mitigating circumstances. Our policy is a minimum of every 2 hours the primary care nurse must check and chart on each patient. The CNA's catch them between (if we have any).

Brownms46 · May 4, 2004

Where do you work that 12-14 patients between two nurses at night is too many? That's a 6-7 to one ratio. Most night nurses in a med-surg unit would give their eye teeth for that kind of assignment. The real question is... why was the patient unattended for that many hours? In defference to all the wonderful LPN's out there - THIS LPN should have been making rounds AT LEAST every two hours.[/quote
Where I am contracted to work now,...the ratio is 6-7, with an RN/LPN team. 3/3 if 6 pts., and 3/4 if there are 7 pts. Also this is the ratio at another hospital in Seattle. Anymore than that and the CN takes pts.
This is the only way I will work on the floor!

mounceb · May 4, 2004

Where do you work that 12-14 patients between two nurses at night is too many? That's a 6-7 to one ratio. Most night nurses in a med-surg unit would give their eye teeth for that kind of assignment. The real question is... why was the patient unattended for that many hours? In defference to all the wonderful LPN's out there - THIS LPN should have been making rounds AT LEAST every two hours.[/quote
Where I am contracted to work now,...the ratio is 6-7, with an RN/LPN team. 3/3 if 6 pts., and 3/4 if there are 7 pts. Also this is the ratio at another hospital in Seattle. Anymore than that and the CN takes pts.
This is the only way I will work on the floor!
No, you misunderstood. It was 14 patients to ONE nurse. 27 on the floor, one nurse had 14 the other had 13. That is too many.

JERRY MARTIN · May 4, 2004

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?

I BELIEVE THAT THE RN SHOULD HAVE HAD SOME SORT OF DISCIPINARY ACTION AS WELL.I AM AN RN STUDENT MYSELF AND THE ONE THING THAT DOES HAPPEN IN NURSING IS SOME PEOPLE PAY FOR THE MISTAKES OF OTHERS AND IT DOES APPEAR TO ME THAT THE LPN IS TAKING THE BRUNT OF PUNISHMENT.I HOPE SHE DOES NOT GET HER LICENSE TAKEN AWAY FROM HER.

sockov, ADN, ASN, BSN, CNA, LVN · May 4, 2004

:angryfire :uhoh3:

Nursing seems to be the major backbone for the hospitals and the major scapegoat as well. If you feel the assignment is unsafe, then you can legally refuse to take the assignment BEFORE YOU TAKE REPORT. Once you take report, you have already begun to establish the patient-nurse relationship and then it could be termed abandoment, if then you decide to refuse.

Once, where I worked, the day and evening shift got together to unify and start refusing assignments before the shift would start. I would work days, and stay on OT while the 3-11 shift is with administration demanding more help. At this time we were caring for 10-12 patients with one CNA to help. This was a sub-acute rehab. and the patients werent agile, and some still sick.

You could never get out on time, and the big-wigs would harrass you for having OT. Also, taking care of 12 patients, with one cna and having about 2 admits, and all the iv's and central lines.... it got over-bearing! I worked mostly with LVN's (same as LPN in california), and we were all overworked the same.

So we were fed up and decided to refuse assignments if the numbers didn't look good, or deem safe. All in all, powers in numbers,we had our way for about 3 weeks, then slowly it went back to the way it was. No staff, and more to do. So, after that I went per-diem and then studied and went into critical care.

I think finally people are realizing the dangers of short staffing of nurses, and how it impedes care and makes the patient stay longer in the hospital.

All divisions of nursing is short staffed. Especially critical care~! Hospitals better start realizing that nursing is what makes or breaks them, and start making the profession better to work in, not harder!

California right now is the only state to mandate safe staffing ratios. They are safe numbers, and hopefully more states will follow.

oh my my.