Neglect...LPN was fired, RN was not - page 9

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... Read More

  1. by   Tweety
    The standard on our unit is q2h checks. With two professionals covering 12 patients, that's six apiece, q2h checks can be done. Doesn't mean your doing vital signs and head-to-toe q2h, just means your checking them. Of course patient condition may warrant more frequent checks. But q1h anything needs to be in the ICU in my opinion.

    I'm not saying that six patients per professional is fair and safe. I would like to see lower ratios, just that is the way it is right now on med-surg in this area. There are places and units with even higher night shift ratios than that.
  2. by   meownsmile
    Please let me clearify again,, with 3 staff assigned to 10-12 patients,, someone is up and down the hall all the time and q1 hour VISUAL checks are done,, as basic safety precaution.
  3. by   Tweety
    Let me also clarify, I'm not in California with a mandated staff ratio, so perhaps this is why I'm not really bothered by the 12 patient assignment between two professionals, because it's so common here.

    Moral: Don't move to Florida.
  4. by   BBFRN
    I agree 100% with -jt. And as an experienced LPN, I do feel comfortable taking responsibility for a GI bleed pt- but included in that responsibility is making sure I alert the charge RN to any changes I see in the pt's condition, checking the pt's labs, etc. If anything, I think this is also a good reminder to chart when the RN is notified of pt condition. Who knows if this particular LPN did that? Even if she did, the RN could say she didn't if it wasn't documented. I'm also wondering if the LPN charted that she did q2h checks on all her pts on the flowsheets. This would also make her legally liable, wouldn't it?

    Regardless, an Assignment Under Protest form could've come in handy for both nurses involved. 2 nurses on any med/surg floor is too few. What if the pt had coded, and they caught it? Who would've been there to watch the other pts while they were dealing with that?
  5. by   Hellllllo Nurse
    Quote from fergus51
    I do think the RN is responsible for her patients. But if this floor allows them to split teams of patients like this, then the RN can't possibly be responsible for doing everything for all of them. If she is, then what is the point of even having LPNs? If a facility allows delegation by RNs to LPNs that means they are competent and able to do the job without an RN standing behind them. The question to me is who was responsible for checking that patient? If it was the LPN's patient, then I assume it was her. An LPN doesn't need an RN to hold her hand while she checks to see if someone is still breathing.

    If an RN can't delegate to an LPN within their scope of practice, what's the point of having LPNs? Is the RN responsible for everything the LPN does? If that's the case, then it seems like the LPN is working on the RN's lisence and as far as I knew LPNs have their own lisences.

    I have to say, this is one reason I prefer primary nursing.
    Exactly. Being and LPN carries not only the right to call yourself a nurse, but also the responsibily of being a nurse. If LPNs can't be responsible for their own pts, under their own licensure, then why would we need LPNs? If this nurse does not want to be held legally responsible for her pts, she should be a CNA, not a nurse.
  6. by   Tweety
    Quote from Hellllllo Nurse
    . If LPNs can't be responsible for their own pts, under their own licensure, then why would we need LPNs? If this nurse does not want to be held legally responsible for her pts, she should be a CNA, not a nurse.

    There's that silly nurse practice act that says it's the RN that's responsible for the patients. Sucks doesn't it?
  7. by   mattsmom81
    Quote from 3rdShiftGuy
    There's that silly nurse practice act that says it's the RN that's responsible for the patients. Sucks doesn't it?

    I don't believe my particular NPA/BNE would judge this situation this way. We need to all research our own NPA's to be sure.

    In the situation described in MY state in MY facility, If that LPN came to me and said she was uncomfortable with that patient and could I take over this patient or assist her, and I failed to ensure the patient was safe, etc etc...then yes I might share responsibility. I might be questioned about policies and procedures ie were they followed, perhaps risk management would take a look at how the delegation was done... but I doubt I would carry liability for what she did or didn't do for her patient in a primary care setting. The LPN accepted the assignment, she has a license, she is responsible within the LPN scope of practice.

    I was a LPN prior to becoming an RN. I never expected the RN would share responsibility for my INDEPENDENT actions or failure to act in a single instance. But I have practiced in 2 states only so perhaps other states and individual P and P's will vary on this issue.

    I'm NOT one of those RN's who claim 'LPN's work under my license'.

    It all boils down to know your NPA and facility policies.
  8. by   plumrn
    I have read through most of the replies on this thread. Just a few thoughts along the way...

    First of all, if the pt was a 'critical' GI Bleed, he would be admitted to ICU. The GI Bleed diagnosis doesn't mean they are unstable, and is a very common diagnosis on a typical med/surg floor. We usually have several with that diagnosis on our med/surg unit on most days. If they should become unstable, they are transferred to ICU.

    We really know very little about this particular situation, and he may have had a hgb of 12 for 3 days, and considered stable for all we know. The problem here is, he wasn't checked on for several hours.

    It is in an LVN's scope of practice to monitor and report any changes in condition to the RN. This would be a reasonable, & prudent expectation of the RN, that the LVN would check her pts at least every 2 hours. If the LVN fails to do this, then she failed at her job. If the RN isn't informed about a change, then she shouldn't be held accountable for something she did not know. It is impossible for the RN to have a full load of pts, and to also know everything that is going on at all times with the LVNs pts., or with the LVN. As an LVN, she is perfectly capable of monitoring whether a pt is breathing, or is lying on the floor. This is where the LVN breeched her duty. NOT that she didn't report a change in condition, but that she neglected checking on the pt. often enough. If this was the case, I do not feel the RN should have been fired.

    If you have 6 pts who are not too sick, and don't have too many needs, you could probably care for them safely. However, if you have 4 pts who are very ill, on heparin protocols, sliding scale blood sugars q4h, turn q2h, feeding, incontinent hourly, multiple meds & treatments, needy families, etc., then you might not be able to provide safe care for even these 4. I hate it when management only looks at numbers, and rarely the acuities of the current census.

    What if there were 20 pts on the floor, and the staffing was 1 RN, and 2 LVNs? Does that mean the RN would be responsible for her own pts in this mix, PLUS doing @ least q2h rounds, plus assessments on all 20 pts?!!

    I have read that once you take report, it is considered pt abandonment if you don't take the assignment. How do you know if it is safe or not, until you have heard the report? 10 really sick pts, would be unacceptable, but 10 easy ones would not be. How about if you accept the 10 easy pts, but then sometime during your shift a couple of them develop serious problems. Shouldn't you then be able to say, "Well, now this assignment is unacceptably unsafe due to higher acuity, and I shouldn't be held accountable if the rest of the pts don't receive the best of care?" -and make a formal request for more licensed staff.

    Just wondering.

    I thought of more things as I was reading thru this thread, but now I am too sleepy to think of them, and have to go to bed.
  9. by   Tweety
    Quote from mattsmom81
    I don't believe my particular NPA/BNE would judge this situation this way. We need to all research our own NPA's to be sure.

    I agree. While the act states that the RN is responsible for all outcomes, when you go before the board theu look at the whole situation. Take the med error situation, what would a resonable and prudent RN do if an LPN makes a med error. It is only after the fact that the RN is aware of the situation. I'd like to think the RN isn't going down for making the med error, only for the actions afterward, the assessment, calling docs, treatment and monitoring, etc.
    Last edit by Tweety on Apr 22, '04
  10. by   leslie :-D
    i think when you're responsible for delegating, there has to be some level of responsibility on the rn's part. but let's put it in its' context. as an rn, i will be vigilant about who and what i delegate but neglect acts under its' own merits. i personally feel compelled to oversee everything i delegate, but then again, i tend to be paranoid sometimes.
  11. by   Hellllllo Nurse
    Quote from fergus51
    Well Brownie, that's why I like working with an all RN staff. I don't need to worry about an LPN not noticing her patient has been dead for hours and me being held accountable for that. If you can't even trust someone to do their checks, I would rather not work with them. To me, delegation means delegation it doesn't mean I stand there and supervise. She wasn't asked to perform brain surgery. I would think an LPN would be insulted if I said "Did you check your patients? Are you sure you did? Are you sure they are breathing? Maybe I should watch you check them just to make sure. In fact, maybe I should do all your work because I can't trust you to do it"....

    Excellent post, Fergus.
  12. by   NursesRmofun
    Quote from nurseunderwater
    For some Tweety this may be true, not for all.....

    And we all know where that discussion leads... :uhoh21:

    another example of the need for a "clearer" more standardized scope of practice for "us" LPN's.....
    I agree! Amen! I think that the scope of practice for LPNS & RNS, respectively, should be across the board in every state and in every facility. They either can or they can't. They either are responsible for this or that or aren't, etc. That would help a great deal!
  13. by   Hellllllo Nurse
    Quote from 3rdShiftGuy
    There's that silly nurse practice act that says it's the RN that's responsible for the patients. Sucks doesn't it?

    The practice act says the RN is ultimately responsible.
    However, LPN in this case was primarily responsible. The LPN failed to provide minimal care. The LPN appears to be guilty of breach of duty.
    The RN was not assigned to the pt who died.

    If either nurse is sued, perhaps they can use the Aiken Study as evidence of the hospital being responsible for the pt's death, due to inadequate staffing.

    I have recently transferred to an all RN dept where I work. It is such a relief not to be responsible for the actions of others anymore!

    In my old dept (hemodialysis) I worked w/ an LPN who discharged a pt to go home w/ a B/P of 49/29. Somehow, this pt had managed to stagger to his truck and get in. I ran out to his truck, and stopped him just as he was trying to put the key in the ignition.
    I drug him back inside and stabilized him. He was stable enough to leave about an hour later. This LPN is very agressive and insubordinate. She is one of the reasons I left the hemo dept. She did not understand why I did what I did. She actually said "You need to assess the pt based on what is normal for him, not what is normal for you." (the pt's baseline B/P is low).
    I tried to explain to this mental giant that a B/P of 49/29 is not normal for anybody. But, she wouldn't hear it. Ignorance combined with arrogance is a dangerous combination in a nurse.

    She is currently flunking out of her RN prereqs. But, she is chomping at the bit to be charge nurse of the unit, which requires an RN.
    I'm sure she will get her RN eventually. I wonder how she's going to like being responsible for the actions of other nurses. I hope she doesn't have to work w/ another LPN like herself. Hmmmm.... or maybe I really hope she does. She could use a taste of her own medicine.

    Here is another case of a nurse being held responsible for the actions of another-

    I have an RN relative who works at an inpt lock-down psych unit.
    An LPN there was passing meds. One pt refused his meds, so the LPN mixed them in w/ the pt's food, which he then ate. Afterwards, the LPN told the pt what she's done. The pt got a lawyer and is suing for violation of his rights. The charge RN on duty that day (who did not even know what the LPN had done) is being held accountable by the hospital for the actions of the LPN.
    Totally unfair.
    Being an LPN does not excuse one from being competent and providing minimal care.

    BTW- I was an LPN for seven years and have been an RN for four.