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?

[NannaNurse]

The funny thing is..........we do aquity ratings every darn shift........for what?? We have a rating of 0-3+.........about 45% of our patients are 2-3+ and this means nothing.........we have 22 patients and they are ALWAYS divided up 3 ways........we are getting ready to move to another floor while our 'new rehab floor is being built'...and we are going down to 20 pts. We will be on a unit with med-surg who will have 10 pts........if their lights are going off, etc.........I see nothing but trouble with this one.....In our 'new' place, we will move up to 30 pts........man-o-man-o-man-o-man........are they hiring at Starbucks???

[meownsmile, BSN, RN]

Nana,, im not that far from you and they do the "acuity" staff ratios every shift also. It means nothing here either, They still staff by numbers, and its usually 10 average per RN on days unless the census has dropped. I have said it before, they use their acuity tracking program each shift and it looks good when someone comes in and wants to see it, and thats about all its for. They sure dont bother using it when it comes to daily staffing.

[Brownms46]

Again, I'm not saying the RN is an innocent bystander in this case, just that the "punishment" should take the RN and the LPN separately and should be appropriate to violations each incurred.

I didn't mean to say I didn't want LPNs in my assignment. Daily I'm assigned one, if not more LPNs and I accept it.

What bothers me about the RN being responsible for every outcome is when I've been off several days I know nothing about anyone in my assignment. The assignments are made by the charge nurse from the shift prior. And the way we use LPNs is as total care providers not teams, so literally my license is dangling on the line every day, since it may be way into our shifts that I realize that an assignment might not be appropriate, or what the LPN is and isn't doing.

Once I was working with an LPN who decided to let a patient sleep through his 4AM vitals. The patient went into septic shock and it was only then that I was aware of the situation. Sigh..........sometimes makes me crazy.

Anyway good discussion, even if we don't agree on the fine points. :)

You know...Tweety...I really do see, and understand your position here.

I believe this RN wished she had supervised this LPN more closely, or maybe had peeked in on this pt. I sure she has gone over, and over in her head, what she could, or would've done differently....given the chance.

For the LPN...I don't know what could've caused her to not look in on this pt. for 3-4 hrs! But I do believe...she would've done things differently also. For the rest of her life...she must live with the fact, that her carelessness...caused the death of another! Don't think I could function anymore...if this happened...ooooh please God forgive me for even writing such a thing! This is a mind blower for sure...no matter how many people are at fault! NO two ways about it!

On some level .....I feel you are right...that maybe the RN shouldn't have been fired...but definitely given more than just a slap on the wrist. However, I do believe this RN has not heard the last of the situation.

[-jt]

The staff's debate shouldnt be about which one of the nurses should be fired. That focus is misdirected. The hospital and supervisor who allowed that kind of staffing, knowing it puts pts at risk, should be the ones the arrows are aimed at. Hold THEM accountable. Thats where the staff's anger over the situation should be directed - the fact that nurses (LPNs & RNs) are being put into impossible situations by supervisors, have no control over those decisions, but are being crucified for the adverse effects it causes.

How are you going to check a pt & provide care q 1 hr on a med-surg unit if you have 12 pts? Q 1 hr care is INTENSIVE care & we can do it in ICU because we only have 2 pts. What did the nurse do wrong? What was she fired for? Was it because she didnt see the pt for 3 hrs? What is the norm on a med-surg unit anyway? How does anyone know the nurse was just "careless"? What else was going on the unit at the time and with her other 11 pts? 3 hrs between rounds doesnt seem unreasonable - especially if you have 12 pts to provide hands on care for, plus all the charting, meds, problems that may come up, ect. How can a nurse be expected to do all that for 12 pts AND check each one of them every hour? You could spend a whole hour in just one pts room, depending on the care the pt needs.

If the policy was that the med-surg nurse MUST check each pt every hr, then the nurses should have put it in writing that it would be impossible to follow the policy with the kind of staffing they had to work with. They then could not be held responsible for not following the policy or used as scapegoats when an incident occurred because of it.

IMO, neither of the nurses should have been fired when they were forced to work in an unsafe situation that was set up to fail & it subsequently did. And the staff should not be arguing over which one to fire. They should be outraged that anyone was fired at all and that they are being forced to work in unsafe situations and held accountable for it.

To refuse an assignment is insubordination and we can be fired for that but we do have the right to protest an assignment & not carry all the liability for an unsafe assignment alone.

The mistake the nurses made was not putting in writing that they recognized that this was an unsafe assignment & they were doing the best they could under the circumstances (ie: fill out a protest/assignment under objection form or even just a note to the supervisor). If the supervisor then allowed the staffing to remain as it was, the liability for whatever ill affects it caused would have clearly been on the supervisor & hospitals shoulders and that does stand up in court.

[Nitengale326]

I personally think the actions were appropriate. The best thing for you is just to lay low and not get involved in the politics of this debate. Trust me, there will be another debate next week. I too have been an LPN and then onto my RN. Good luck

[SmilingBluEyes]

EXCELLENT POST -jt!!!!!!!!!!!!!

[nurseT]

God, that's awful. Severe neglect. 8-9 pts. Hmm. I have worked the skilled unit at LTC with 18 pts. Many different things going on. The skilled units now are like little hospitals. Pts get kicked out so soon now. I've had central lines, picc lines, mid lines,infusaports, peripheral lines, peg tubes, post surgicals with infected wounds, fresh amputees, pts being preped for tests, coordinating Dr. appts, new admits, discharges, admin all meds and txs all in one day, with one cna. I always new if someone fell. I thought 18 pts was too many. I can promise you i never walked the hall, I ran every where I went. Don't offer your opinion to your coworkers, just shake your head and start looking for a better job.

[meownsmile, BSN, RN]

jt,, the OP wasnt talking q1hr checks,, that was my post about our falls program. And we do VISUALLY check patients on the program every hour whether it be as we are walking down the hall to another patients room or have a few minutes to go check. We have a system that alerts us to which patients are on the program and they are again,,, VISUALLY checked every hour, to make sure they arent getting out of bed unassisted, with q2 toileting,turning. In no way did i mean to imply that we went and did physical checks every hour,, that is intensive care and not available on a med/surg floor. Sorry for the confusion.

[Tweety, BSN, RN]

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.

[meownsmile, BSN, RN]

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.

[Tweety, BSN, RN]

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. :)

[BBFRN, BSN, PhD]

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?