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?

[ninaldunn]

Wow, this is a scary story. We also team, everyone wants their assignments per region. (I'll take the first 3 rooms, you take the next 3 rooms). I always struggle, especially because maybe the LPN had these pts for 2 days, and wants to keep them, even though 1 is not so good. As an RN, I would want the most unstable patients, however, a GI Bleed bowel prepping would probably be one of the more stable patients, unless he had a hemoglobin of 7.2. If I do give a trusted LPN a patient who is borderline, I do try to get in to see them. Not necessarily to assess them, but at least to eyeball them. (most of our LPN's are very experienced & float) But, being I have heavy patients, I don't always get in there. I will ask during the shift, maybe at break/lunch time - How's our stroke girl? I work an Ortho floor, so if we have a CVA pt, I always ask if my teammate LPN or RN is comfortable doing neuro checks, and I ask them to get me to help with turns, or washing them up so I can get a peek at the patient.

[Brownms46]

Wow, this is a scary story. We also team, everyone wants their assignments per region. (I'll take the first 3 rooms, you take the next 3 rooms). I always struggle, especially because maybe the LPN had these pts for 2 days, and wants to keep them, even though 1 is not so good. As an RN, I would want the most unstable patients, however, a GI Bleed bowel prepping would probably be one of the more stable patients, unless he had a hemoglobin of 7.2. If I do give a trusted LPN a patient who is borderline, I do try to get in to see them. Not necessarily to assess them, but at least to eyeball them. (most of our LPN's are very experienced & float) But, being I have heavy patients, I don't always get in there. I will ask during the shift, maybe at break/lunch time - How's our stroke girl? I work an Ortho floor, so if we have a CVA pt, I always ask if my teammate LPN or RN is comfortable doing neuro checks, and I ask them to get me to help with turns, or washing them up so I can get a peek at the patient.

Although I don't agree about the GI pt., especially since there is no real info given. It would depend on his underlying problems/DX, his speed of bleeding or how he tolerates it. As for his H&H...it would also depend on the pt. age/dx..etc.

But I do wish to say...I like the way you supervise, and maybe if that RN has asked the LPN about her pt. during the night...she might have remember to go check on him:).

[mattsmom81]

The nurse who did not check his/her patient for 5 hrs is likely the nurse that will be focused on if this goes to trial or a report to peer review/BON. If I am in charge and my LPN coworkers and I BOTH have full patient assignments I will likely NOT make rounds on her patients. My duty is to delegate, the LPN/PCT's duty is to keep me informed and look out for their assigned duties. My legal responsibility is limited UNLESS I put my hands on that patient personally, actually.My role is to delegate, assist, advise, WHEN NEEDED etc...doesn't mean I am wholly responsible. Let's not be so quick to make the RN responsible for 'everything'. If we do, why have a license for LPN's???

[justjenn]

I, as a SPN had an expierence last week that is still haunting me. We have started "team nursing" 4 pt.'s per 1. charge nurse, 1 med.nurse & 2 pt. care nurses. Ok - well, we were short 1 pt. care nurse, so I had 4 pt.'s to shower, feed, dress, do assessments, treatments & change beds in 3 1/2 hrs. in a nursing home that I had only been to 2 times last year. (this may seem like cake to some of you, but remember, I am a student & am not real fast). Well, to make a long story short, I ran my butt off & tried not to ask for help. In the "real" world, I may have to do this, so, I tried to handle it myself. Apparently, the stress showed on my face & the student med. nurse helped me out & gave one of my pt.'s a shower. The scary thing to me is that, I was so busy going from one to the other giving showers & handing out meals trays - I was unable to get back to all of them & check to see how they were doing. Someone could have choked on their breakfast while I was getting "hosed down" by a patient in the shower & who relieved themself after they were all clean.

I felt that I was very neglectful, but besides for asking for more help, I do not see how in the blazes I could have done any better. If something did happen to one of those patients, I would have taken full blame.

But, getting back to the LPN, RN thing. Honestly, how does one say "I cannot do this assignment." What does one do - you have a RN & LPN, thats it. So then what?

Is not the hospital to blame because they do not staff their floors? Aren't they the ones who are really very neglectful? Why should they have put their nurses in that kind of situation?

Anyway, my too cents.

justjenn

[fergus51]

You know what fergus, I don't care who I work with, as long as they work! This LPN was totally wrong in not checking on this pt. sooner! However... I have read on here, and heard many a nurse state, how they were so busy with a couple of their pts. that none of their other pts. ever saw them! I KNOW this has happened to many! I feel the RN, "should" have made rounds on everyone, especially if the LPN had more assigned pts. And even if she didn't! And that still does not excuse the decision making on the part of this RN to accept the assignment, and to assign this pt. to the LPN to care for.

But I also know that it is NOT because this was an LPN, that this pt. didn't get seen! I have worked with a few RNs, who I have wondered where they head was. Worked with two recently, who must have forgot where they were, because they definitely weren't concentrating on what they were supposed to be doing! Too many errors made..as one was too sleepy to have even been at work!

Negliegence comes in all titles...all the way up to MD!

No matter, because I guess I won't be reading on here, that the "RN is ultimately responsible" anymore. Because obviously from the responses, and the outcome of this event...that is not neccesarily so:D!

I certainly don't mean to imply that just LPNs are incompetent. I just mean if an RN is incompetent, I don't have to worry about my job. I don't like the idea of working with an LPN if I have to stand over her shoulder or be responsible for my job and her job. I don't think I am responsible for another lisenced professional's job. If an LPN isn't responsible enough to check on her patients and I am expected to follow behind her or risk my lisence, then I don't see the point of even having them on staff. Probably why my unit doesn't.

[Sheri257]

B. CMR 3.02 Responsibilities and Functions-Registered Nurse which states, "A registered nurse (.e.g., Directors of Nursing), within the parameters of his/her generic and continuing education and experience, may delegate nursing activities to other registered nurses and/or health care personnel, provided, that the delegating registered nurse shall bear full and ultimate responsibility for the outcomes of that delegation"... "and make informed judgements therefrom as to the specific problems and elements of nursing care mandated by a particular situation." Responsibilities and Functions also state a registered nurse will "collaborate, communicate and cooperate as appropriate with other health care providers to ensure quality and continuity of care" and will "serve as patient advocate.'

Thanks for this info. What statute or regulation is this? State or Federal?

Also, I was wondering if there are any similar guidelines which govern how you handle turning down such assignments, if any. I noticed that people mentioned protesting in writing or just simply saying no, but are there actual procedures defined by the BONs or other regulatory authorities?

I'm just a lowly student interested in learning more about this.

:uhoh21:

[Brownms46]

The nurse who did not check his/her patient for 5 hrs is likely the nurse that will be focused on if this goes to trial or a report to peer review/BON. If I am in charge and my LPN coworkers and I BOTH have full patient assignments I will likely NOT make rounds on her patients. My duty is to delegate, the LPN/PCT's duty is to keep me informed and look out for their assigned duties. My legal responsibility is limited UNLESS I put my hands on that patient personally, actually.My role is to delegate, assist, advise, WHEN NEEDED etc...doesn't mean I am wholly responsible. Let's not be so quick to make the RN responsible for 'everything'. If we do, why have a license for LPN's???

mattsmom I didn't make the RN responsible for everything, just for the supervision she was supposed to provide to ensure the patient assignment she delegated was carried out. I also stated this LPN was very responsible for this pt. not being seen. You can delegate, but the you still hold ultimate responsibly for your decision to delegate, and for the outcome of that delegation. Or did I miss something in the rules of delegation?

[smk1, LPN]

Thanks for this info. What statute or regulation is this? State or Federal?

Also, I was wondering if there are any similar guidelines which govern how you handle turning down such assignments, if any. I noticed that people mentioned protesting in writing or just simply saying no, but are there actual procedures defined by the BONs or other regulatory authorities?

I'm just a lowly student interested in learning more about this.

:uhoh21:

another student here seconding this request for more info. have nay of you rejected an assignment and had negatvie effects result? positive? how have you done it?

[Brownms46]

I certainly don't mean to imply that just LPNs are incompetent. I just mean if an RN is incompetent, I don't have to worry about my job. I don't like the idea of working with an LPN if I have to stand over her shoulder or be responsible for my job and her job. I don't think I am responsible for another lisenced professional's job. If an LPN isn't responsible enough to check on her patients and I am expected to follow behind her or risk my lisence, then I don't see the point of even having them on staff. Probably why my unit doesn't.

fergus I know you didn't mean LPNs are incompetent, and really I don't blame any RN who doesn't wish to delegate to an LPN. I have nothing against anyone doing what they feel comfortable with.

On my first night to one hospital, I had an RN come in and watch me give insulin, do a blood draw, and an ekg. I had no problem with that, as that was her right to do so! And yes...I uderstand some RN preferring to work with an all RN staff, and don't blame them one little bit.

However...this is the way the system is set up, and I have heard, and read many an RN state how we work under them, and that they are responsible for what we do...or don't do. Now all of sudden... no one is saying that.

What I am saying is....you can't have it both ways. Either you are or you aren't responsible, and LPNs are responsible for their own actions/inaction. I mean I have also read on here, how LPNs work under the RN's license..etc...etc. So I am just trying to figure out...which is it?

[Brownms46]

Thanks for this info. What statute or regulation is this? State or Federal?

Also, I was wondering if there are any similar guidelines which govern how you handle turning down such assignments, if any. I noticed that people mentioned protesting in writing or just simply saying no, but are there actual procedures defined by the BONs or other regulatory authorities?

I'm just a lowly student interested in learning more about this.

:uhoh21:

I think ...but not totally sure...that I found that on N. C.'s Bon Practice Act.

Here is more:

ACCEPTING ASSIGNMENTS:

The licensed nurse is accountable for the care that he/she provides to the client, as well as all nursing care which the nurse delegates to other staff members. Therefore, it is essential that each nurse have the knowledge and skill to perform an activity safely before accepting such a responsibility.

When a licensed nurse comes on duty to find that the mix or number of staff is not adequate to meet the nursing care needs of the patients, what should he/she do? Before accepting the assignment, the nurse should contact the immediate supervisor to report the unsafe situation and ask for assistance in care planning based on the available resources within the agency. Such assistance may include:

acquiring more staff

negotiating "periodic" assistance from the immediate supervisor for delivery of specific care activities

prioritizing the care activities that will be delivered during that shift or tour of duty; and

notifying other health care providers regarding the limitations in providing optimal care during periods of understaffing.

Although it may be impossible to deliver the type of nursing care that would be delivered with a full complement of staff, there are certain activities that must be carried out regardless of staffing. These activities include:

accurately administering medications and implementing critical medical treatment regimens;

protecting clients at risk from harming themselves;

monitoring client's response to medical and nursing interventions consistent with each client's health care problem;

notifying the physician of deteriorating or unexpected change in a client's status; and

accurately documenting the care delivered to the clients.

WHAT CONSTITUTES ABANDONMENT?

The following activity may result in disciplinary action by the Board: . . . "abandoning or neglecting a client who is in need of nursing care, without making reasonable arrangements for the continuation of care." [21 NCAC 36.0217 © (10)]

Abandonment can only occur after the nurse has come on duty for the shift and accepted his/her assignment. If the licensed nurse leaves the area of assignment during his/her tour of duty prior to the completion of the shift and without adequate notification to the immediate supervisor, it is possible that the Board would take disciplinary action. However, when a nurse refuses to remain on duty for an extra shift or partial shift beyond his/her established schedule, it is not considered abandonment when the nurse leaves at the end of the regular shift, providing she/he has appropriately reported off to another nurse and has given management notice that the nurse is leaving. NOTE: If a nurse resigns and does not fulfill the remaining posted work schedule, this is not considered abandonment under Board of Nursing regulations.

NURSE MANAGER ACCOUNTABILITY:

During periods of understaffing, the nurse manager may have to reassign staff to different patient care areas, as well as approve extended tours of duty (i.e.: double shifts) for nurses who volunteer or agree to work extra. If a nurse has agreed to extend his/her hours of duty due to short staffing, but has informed the nurse manager of a limit to the extra hours they will work, the nurse manager is responsible to provide a nurse who can accept the report and responsibility for the patients from the over-time nurse. If a replacement nurse cannot be found, the nurse manager is responsible for providing the coverage. Failure of the nurse manager to respond to calls from the nurse on duty does not alleviate her/him of responsibility for providing coverage. [G.S. 90-171.20 (7)(j)].

The nurse manager is accountable for "assessing the capabilities of personnel in relation to client need and plan of nursing care . . . and delegating responsibility or assigning nursing care functions to personnel qualified to assume such responsibility or to perform such functions. " [21 NCAC 36.0224 (i) (2) (3)] This includes making a judgment about situational factors which influence the nurse's capabilities for delivering safe nursing care to clients. For example, the staff nurse who accepts a "double shift" and then must return for the next regularly scheduled shift with only a few hours off may be significantly sleep deprived, and thereby, not competent to provide safe care. The nurse manager must carefully assess the capabilities of this nurse before delegating nursing care activities/responsibilities to him/her. It is important for nurse managers to remember that they could be liable for disciplinary action by the Board for delegating responsibilities to a staff nurse when the manager knows or has reason to know that the competency of the staff nurse is impaired by physical or psychological conditions [21 NCAC 36.0217 © (6)]. Physical impairment may include but not be limited to fatigue or sleep deprivation.

WORKING TOGETHER TO PROVIDE SAFE CARE:

Both nurse managers and nurses in direct client care positions are accountable for providing safe nursing care to their clients. During periods of understaffing or limited numbers of well-qualified staff, it is essential that nurse managers and nursing staff work together to provide safe care to all clients in a manner consistent with nursing law.

[Tweety, BSN, RN]

The nurse who did not check his/her patient for 5 hrs is likely the nurse that will be focused on if this goes to trial or a report to peer review/BON. If I am in charge and my LPN coworkers and I BOTH have full patient assignments I will likely NOT make rounds on her patients. My duty is to delegate, the LPN/PCT's duty is to keep me informed and look out for their assigned duties. My legal responsibility is limited UNLESS I put my hands on that patient personally, actually.My role is to delegate, assist, advise, WHEN NEEDED etc...doesn't mean I am wholly responsible. Let's not be so quick to make the RN responsible for 'everything'. If we do, why have a license for LPN's???

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.

[Tweety, BSN, RN]

What I am saying is....you can't have it both ways. Either you are or you aren't responsible, and LPNs are responsible for their own actions/inaction. I mean I have also read on here, how LPNs work under the RN's license..etc...etc. So I am just trying to figure out...which is it?

I don't mind being responsible, I know that's the role of the RN and the way it's set up. I've accepted that responsibility.

But if an LPN makes an error that kills a patient in an assignment that I've made out, and it was a safe assignment, and the LPN was competent to complete the assignment, I still maintain I shouldn't receive the same "punishment". Sorry, but I feel strongly about that. :)