rn taking orders from an lpn?

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Specializes in ltc/snf.

Background: I work in a skilled rehab nursing facility. I have been a nurse for 9 months. This is my first and only job as an RN. Most shifts I am the only RN on the floor, responsible for close to 100 pts. My day supervisor is an LPN. She leaves by 5pm then its me for the entire building caring for my own 25 pts plus overseeing 3 LPNs and the other 75 pts in the building until 11pm. I am not a supervisor.

I had a pt today that has a hx of ALC, going AMA, and head trauma. She is a very acute pt with a PICC, 2 jp drains and psych issues to boot. Today she had an episode where she was sitting in her chair talking with her family and all of a sudden her eyes rolled back, and slowly fell to to floor from her chair. When I found her she was on the floor unresponsive, limp, pupils not reacting but alive. VS were normal. Gave her some o2 and stayed with her until medics arrived. Sent her to the ER for eval and tx.

Meanwhile I am the only RN on the floor. My "supervisor" is an LPN and was not in the building. She called me from her home and told me that our DON told her to tell me that if ER does not admit her, that we ARE NOT TO TAKE HER BACK TO OUR FACILITY due to her acuity and hx. So I get report from the ER nurse who says that everything came back negative and they are ready to send her back to us.

Problem: She was never officially taken from our care. She was sent to ER for eval and tx only. I felt if I had followed the instructions of the DON (via telephone from an LPN) that that would be pt neglect and did not want to be responsible for turning away a pt that I had already accepted care for. So I went against orders from my DON and accepted her back into our facility.

So my questions are: Did I do the right thing? Could I have been charged with pt neglect had I not taken her back? Isn't it out of scope of practice to for an RN to take orders from an LPN? Can I get fired for not listening to my DON?

I never actually spoke with my DON and I never heard the words from her mouth. She called the supervisor who is an LPN to tell me "don't take her back." I called my DON several times for a clarification and left several messages but no return call. I felt I made the best decision at the time. I am worried about ramifications next week from DON for not following her orders. but I NEVER HEARD FROM HER DIRECTLY AND SHE WAS UNAVAILABLE!! I know our facility can get into trouble for not have a supervisor in the building.

I am worried about getting fired. My thought at the time was "I would rather be fired than to loose my license." I feel like my DON should have been the one to call the ER and tell them we were not taking the pt back and it was not my place to do that. I feel its was unfair for her to put me in that position. I am sick to my stomach over this. Please any honest advise would be appreciated thank you.

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Well, first, it doesn't matter if the supe is an LPN or RN. Second, when the pt was sant to the ED care was transferred. Third, she is far too acute for a rehab. Fourth, who knows what will happen to your job. The hospital probably wouldn't have kept her, either.

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When I've worked LTC, in a situation where a patient is a problem, we couldn't get "rid" of them via an ER evaluation/treat trip...it wasn't an admission to the hospital, so they're still the LTC's resident. "Dumping" laws are not nice...when someone gets nailed for ditching a patient without going through the proper channels (ie- 30 day notice to the responsible party, attempt to find alternative placement, etc), it can be big trouble for the LTC.....it's not even an issue of LPN. I've worked in facilities where the ADON is an LVN and it worked out that if she gave an order speaking for administration while she was on call, nurses were expected to follow through on that (and chart who told them to do what).

Not accepting a patient back after hours is sleazy. You did the right thing. The resident was still on your 'books'. :)

But I know the hopes of someone being admitted, and then not RE-admitted...:twocents:

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Well, first, it doesn't matter if the supe is an LPN or RN. Second, when the pt was sant to the ED care was transferred. Third, she is far too acute for a rehab. Fourth, who knows what will happen to your job. The hospital probably wouldn't have kept her, either.

Only if the hospital admitted her. Otherwise, she was still a resident of the LTC. :)

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Specializes in ltc/snf.

Thank you Sue. I wondered about the transfer of care because she was still technically in our system as our pt and was never admitted into the hospital. that's where my confusion set in. I felt she was still my responsibility...

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Thank you Sue. I wondered about the transfer of care because she was still technically in our system as our pt and was never admitted into the hospital. that's where my confusion set in. I felt she was still my responsibility...

You are correct. :)

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Specializes in ltc/snf.

thank you xtxrn. The LPN I am referring to to is one of the best nurses I know. I want to clarify that I didn't any anyway mean anything like she is "less than me" or whatever. I was just trying to clarify whether or not I COULD technically take orders from an LPN :)

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thank you xtxrn. The LPN I am referring to to is one of the best nurses I know. I want to clarify that I didn't any anyway mean anything like she is "less than me" or whatever. I was just trying to clarify whether or not I COULD technically take orders from an LPN :)

No, I understand :) It can get confusing, especially in the hierarchy happy environment of LTCs :) Most of the nurses I've learned the most from have been LVNs (basically the same as LPNs, though I found that the LVNs in TX had greater ability to expand skills, depending on the hospital/LTC facility they worked in- some could start IVs but not give IVP meds, others couldn't start IVs, but could give any IV meds... it was confusing ;)).

If the nurse is higher up in the administrative chain, yeah, you're expected to follow what they say- but you did the right thing with taking the resident back...copy the link I sent - it's pretty clear (if they give you grief). I know what a pain some patients can be in an LTC that isn't set up for a lot of psych patients. But if you would have dumped them, the hospital could have caused problems, up to issues with Medicaid/Medicare funding (though not usually on the first offense).

Hang in there :)

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Specializes in ltc/snf.

I feel better about my decision after reading that article. My goodness I had no idea that "dumping" was that common of a practice. Its sad really. I'm still bothered that my DON put me in the position she did, not calling ME DIRECTLY with the orders and not being there to answer questions when I needed her. But I do believe I did the right thing and I just hope for the best when I go back to work on Tuesday

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I feel better about my decision after reading that article. My goodness I had no idea that "dumping" was that common of a practice. Its sad really. I'm still bothered that my DON put me in the position she did not calling ME DIRECTLY with the orders and not being there to answer questions when I needed her. But I do believe I did the right thing and I just hope for the best when I go back to work on Tuesday[/quote']

You have federal law on your side...they got squat :)

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Specializes in Respiratory, Cardiac, ED, Maternity, Ped.

First of all i nmy opinion an LPN should NEVER be supervising an RN or functioning in a supervisory role. And I have NOTHING against LPN's (I was one for 4 years). LPN's can NOT take a verbal order. I think you did EXACTLY the right thing!

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