Who is to blame

[Finallydidit]

SCENE SET-UP: Unit 1 = 60 Residents, 2 LPNs, 1 RN, 4 CNAs. Split into two halls..

TIME: 10:30pm (30 minutes before shift change)

RN setting at desk,

LPN #1 charting restocking cart,

LPN #2 on phone with Pharmacy trying to get pain meds (that were supposed to be delivered 6 hours ago) for new admit. (Been playing phone tag with Dr. Pharm most of the evening) Family present and very upset.

CNAs doing last dry round

CNAs for LPN #2 come and say LPN #2, Resident X has fallen of the bed and hit her head. RN and LPN #1 go to evaluate Res. X, because LPN #2 is on the phone.

RN and LPN #1 agree Res. has to be sent out, due to hitting head. (LPN #2 still on phone) RN calls EMS and does paperwork to send to E.R. with asisstance from LPN #1. 10:45 EMS arrives, (LPN #2 still talking with pharmacy trying to get pain meds.) RN handles the transfer, gives EMS report etc. Res. leaves the building.

11pm CNAs, RN and LPN #1 go home. LPN #2 hangs up with pharmacy at 11:10, her whole crew had left, she leaves at 12:30 because she due to being behind because she had been trying all evening to get pain meds for new admit.

3am Res returns from ER diagnosis UTI !!!!! Res. didn't even have head looked at... No one called report to hospital, prior to transport!

8am family showed up and is not happy that a c/t scan wasn't done at hospital, ADON goes to look at nurses note just to see what happened, and nothing was documented anywhere. Who was at fault for this?

LPN #2? Although she was busy with another Resident, and basically had no knowledge of what happened, other then something happened, although it was her Resident that got sent out.

RN ? Her role on evening shift is to asisst LPNs when they get behind, and she left without reporting to LPN #2 what had happened and what needed to be done.

according to the ADON, to appease the family, someone has to be fired! Who would you fire? RN or LPN #2 or both?

I'll tell you the outcome after I get a few opinions...

[netglow, ASN, RN]

RN and LPN #1. Especially RN.

[MAISY, RN-ER, BSN, RN]

Unfortunately, if it wasn't charted and if it was documented that LPN 2 was aware of entire situation-ultimately someone is going to take the blame...it was LPN 2's patient......

HOWEVER...as I work ER, how is it possible the ER nurse did not call the facility looking for information if there was no transfer paperwork initiated indicating why the patient was sent to the hospital? The hospital and its employees bear some responsibility for this, along with the others involved in the processing of this patient.

IF no paperwork exists for transporting to the hospital then it should! Additionally, as one who has received reports from a myriad of sources I would suggest you have a check sheet outlining patient's normal baseline, change in condition, meds given and time, and finally what they are coming in for! We never get a complete story and personally I am sick of people calling who have no idea.....and as they claim they are nurses, make us all look bad!

BTW I don't believe anyone should've been fired, this is a good time to make a negative into a positive with a case study and new solutions so that it never happens again!

M

[Flo., BSN, RN]

No one should be fired.

[caliotter3]

Agree with the answer, RN. However, I also think no one should have been fired over this mistake. Unless it was the last straw for someone with a string of writeups for poor performance.

[MAISY, RN-ER, BSN, RN]

So what was the outcome?

[casper1]

What sense does it make to fire someone.Your facility will be even shorter staffed and their will be more a a chance for an event to occur. Unfortunately this was no ones fault. The Nurses were not sitting around. Dosen't the facility have a Don who could have helped out with the transfer and made sure the right documentation was in place. When I get a transfer from a Nursing home I recieve a list of medications with the last few nurses notes. Also the ambulance transferring the patient should have some documentation on the reason for the transfer.

[prinsessa]

I think LPN #2 should have got off the phone to check on her resident. When I send a resident out I always call the ER to give report. That way they know what the resident is coming to the ER for. I also write the "reason for transfer" on the transfer sheet. Part of being a nurse is knowing what your priorities are. If a question like that was on boards I'm sure the answer wouldn't have been to stay on the phone with pharmacy. Where I work the RNs work the cart just like the LPNs do. We have a supervisor but it is still up to us to check on our own residents. If we fail to do something we can't say "but the supervisor knew" unless the supervisor was supposed to call and give report.

[tvccrn, ASN, RN]

One question...Did the ambulance crew not know the resident hit their head?

[RNBearColumbus, BSN]

Let me preface this by stating that I agree that no one should be let go over this.

I'm willing to bet that LPN #2 would be fired in this situation. Here's the management reasoning I'm going to follow here....

1: the patient that was sent out was her responsibility, regardless of who went to investigate the fall.

2: even tho LPN #1 and RN did the investigation, and sent the patient out, the patient was on LPN 2's assignment. LPN 2 should have made sure all of the "i"s were dotted and the "t"s were crossed before going home. That means making sure required charting was done, and that the hospital was followed up with.

3: LPN #2 should have hung up the phone and dealt with the fall and head injury. A potentially life threatening emergency takes priority over dealing with the pharmacy. (Yes, I realize that the other nurses were helping, but it was still LPN 2's patient, and I'm betting management is going to see it that way too.) Once LPN 2 had sent the patient out, she could have 1) Called the pharmacy back and continued her quest for the pain meds, or 2) passed the pharmacy call onto the next nurses coming on for 11-7.

[nursej22, MSN, RN]

No one should be fired, but certainly some education and perhaps some new, clearer policies are needed. May be check list: EMS called, DON notified, report to ED, family, etc.

Dear Family,

We share your concern about the unfortunate events surrounding your loved ones fall and are taking steps to prevent such an occurrence again. We have performed a root cause analysis and are following up with staff education and a revision of our policies. We believe that a positive approach, rather than a punitive one, will be more effective in the long run for providing appropriate care for our residents.

[imintrouble, BSN, RN]

RN. Life's not fair.

No one being fired was not an option.

The family must be appeased. Does anybody besides me wonder what kind of people demand someone lose their job to make them happy?