Problems with another nurse

[Blinkey]

Sorry that this is long, but this has really been bothering me, and I had to say something...

I am a new RN with less than 3 months experience. I work the overnight shift at a SNF. I am usually the only RN in house, and am ultimately responsible for all of our 90 residents.

I sometimes work with an LPN, who I've decided, after working with her last night, is grossly incompetent at her job. She has been an OR nurse for more than 30 years, and now nearly 70 years old, she is taking her first bedside nursing job. It has come to my attention that her basic nursing skills are long gone, and her common sense is highly questionable. Others on our nursing staff agree, even the CNA's. I honestly do not think that she even knows how to properly assess a patient.

Some of the dangerous things I have heard of, or seen her do includes nearly giving a resident extremely hot water when giving a G-Tube feeding, doing a dressing change on a Stage IV decubiti without personal protective equipment, and last night I personally witnessed her drawing up the wrong medication for a patient having an acute psychotic episode (She was drawing up Zofran, when she should have been drawing up Zyprexa).

In addition to these errors, last night around midnight she was told by our CNA's, who are very good mind you and who know our residents inside and out, that a patient was not right and appeared to be having difficulty breathing. This resident has cerebral palsy and is mostly non-verbal, and frequently makes grunting noises, but our girls new something wasn't right. It turns out she was found to have a massive MI, and is now in the ICU, not expecting to make it through the night.

I had no idea this nurse lacked these basic skills until last night, or else I would have made sure to be personally notified of any of her patient changes of status, so that I could make an assessment on my own. Granted I am a new RN, but I think that my assessment skills are good enough to determine whether or not someone's condition warrants need for further medical attention.

The LPN didn't even do a set of vital signs, the only thing charted was a high temp, which she treated with Tylenol. When someone tells us that one of our residents isn't acting right, it's basic nursing knowledge that you need to make a full assessment of the resident, including a full set of vital signs, and make an educated decision on whether or not the physician and/or emergency services need to be notified.

Even though I knew nothing of what was going on, and she was not one of the patients I provided direct care for; as the only RN in house, I am ultimately responsible for the care of this and every patient under our roof. I feel horrible for what this poor patient had to go through.

From then on, when working with this LPN, I tell all of our CNA's to alert me about anything at all that is going on with our residents, regardless of whether or not I am their charge nurse.

The proper interventions should have been taken, so that this patient could have had a better outcome. I really hope this resident pulls through, but from what I hear, it is highly unlikely.

I just wish I knew, so that I could have done something...

[Altra, BSN, RN]

If you have very concrete examples of substandard nursing care, then it's time to look at your facility's P&P. Are you this nurse's direct supervisor? Then follow your protocol for progressive performance education and disciplinary action. If you are not her direct supervisor, then go to whoever is.

As for the resident who had the MI, realize that, unfortunately, she may well have had a poor outcome even if you were standing right next to her when the infarction began.

You might also suggest that this event be used as an opportunity for all staff to "review" established P&P for evaluating a resident with a possible change in condition.

[Virgo_RN, BSN, RN]

I am an LPN, and I am reasonably competent, but I *always* get an RN to come assess a patient if they are having a change of status (with the exception of a patient who gets PRN respiratory treatments and is c/o SOB; I just call RT).

I don't know about your state, but in my state, the LPN is assigned to care for stable patients. Once the patient becomes unstable, an RN needs to be involved. You might want to check with your state's and your facility's scope of practice for LPNs, know it inside and out, and supervise the LPN's activities closely from here on out.

[squeakykitty]

If you have very concrete examples of substandard nursing care, then it's time to look at your facility's P&P. Are you this nurse's direct supervisor? Then follow your protocol for progressive performance education and disciplinary action. If you are not her direct supervisor, then go to whoever is.

As for the resident who had the MI, realize that, unfortunately, she may well have had a poor outcome even if you were standing right next to her when the infarction began.

You might also suggest that this event be used as an opportunity for all staff to "review" established P&P for evaluating a resident with a possible change in condition.

MLOS has some very good advice here. The nurse that is incompetent needs to be dealt with per policy, and her actions need to be documented. Has anyone spoke with her? What about the times when you are not there? This can't go on, since she is dangerous.

[BlueRidgeHomeRN]

i agree--this lpn sounds like a lawsuit or death waiting to happen. at the very least, if you can't file a disiplinary warning directly, i would disuss this with the nursing supervisor and/or don, and gently but sweetly let them know that you are noting that you spoke with them about your concerns. and...document, document, document....:typing

[RN1989]

You cannot allow someone who is unsafe to continue practicing. You are required by law to report to the BON any nurse that is unsafe to practice. The facilitie's policies have nothing to do with it. You must report this to the BON ASAP or risk your own license and welfare.

[linzz]

If I were in your shoes, I would go to the DON because this situation is unfair to you. Getting a set of vitals and doing a head to toe asmt. as you mentioned, should have been automatic to her esp. after 30 years of working. It amazes me that she kept her OR job that long.

[aeauooo]

70 years old and still working at the bedside?

Just take me out and shoot me!

[Jolie, BSN]

I've never worked in LTC, so please forgive me if this is a stupid question:

Do you file incident reports for unusual occurances? If so, this situation screams out for one. Do you have a QA or Risk Manager who tracks sentinel events? I realize that not all patients experiencing an MI display "classis" s/s. But in a hospital setting, a patient found to have had an MI whose initial symptoms were not assessed beyond having a temperature taken, and who then was "written off" with a dose of Tylenol would be sitting in front of the Risk Manager justifying his/her actions.

[caliotter3]

You are right to be concerned since you are ultimately responsible. Begin to document incidents and counseling as suggested, according to your position as this nurse's immediate supervisor. If you are not her immediate supervisor, then provide your written documentation to the supervisor who is. Don't allow this nurse's incompetent practice to jeopardize you. When somebody has more than 30 years on the job and does not know to take a set of vital signs as part of an assessment when informed of a change in condition, they are dangerous. It would appear that this lady needs to be assisted to come up to par or to retire, but this won't happen until you take charge of the problem.

[pagandeva2000, LPN]

I am an LPN, and I am reasonably competent, but I *always* get an RN to come assess a patient if they are having a change of status (with the exception of a patient who gets PRN respiratory treatments and is c/o SOB; I just call RT).

I don't know about your state, but in my state, the LPN is assigned to care for stable patients. Once the patient becomes unstable, an RN needs to be involved. You might want to check with your state's and your facility's scope of practice for LPNs, know it inside and out, and supervise the LPN's activities closely from here on out.

I am in total agreement with the OP...this nurse may not be competent due to age, skills and cognitive thinking, apparently. Clearly, she is unsafe. There are some basic skills that an LPN should do. However, when the word 'assessment' comes into play...while you can see some competent LPNs do this, legally, we are not supposed to. The word for the LPN is 'data gathering' (semantics, I know). And, yes, the nurse practice acts usually state (I know that my state, NY, specifically says this) that an LPN is to care for stable patients with predictable outcomes. Of course, this is not always what is happening, but once things get shaky, the RN must intervene.

What I really have questions about is why this facility put their patients and other nurses at risk by employing this woman.

[leslie :-D]

70 years old and still working at the bedside?

Just take me out and shoot me!

excuse me???

i'm not sure i'm understanding your concerns.

leslie