Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material.
Summary: Registered and Licensed Practical Nurses frequently delegate responsibilities and tasks to Certified Nursing Assistants and Unlicensed Assistive Personnel. It is clearly recognized that they are responsible for the actions/inactions of those they supervise. In this case, two nursing assistants recognized injuries to a patient while giving a bath. When they failed to notify the nurse of the injuries, they would be reported and lose their certifications.
The patient was a long resident in a nursing home facility, admitted for long term care treatment. As part of her routine the resident on the day in question was to receive a whirlpool bath from a Certified Nursing Assistant. The patient was transported by an assistant to the bathing room. Once the patient was in the whirlpool the second assistant left. The two nursing assistants working under the "supervision" of an LPN.
"Licensed nurses (Registered Nurse/Practical Nurse) within the scope of their practice are responsible for all nursing care that a client receives under their direction. Assessment of the nursing needs of a client, the plan of nursing actions, implementation of the plan, and evaluation of the plan are essential components of nursing practice. Unlicensed personnel may be used to complement the licensed nurse in the performance of nursing functions, but such personnel cannot be used as a substitute for the licensed nurse."2
While preparing the bath, the nursing assistant "tested" the water with a double-gloved hand. Assuming it was the correct temperature the patient was placed in the bath. The CNA realized at that point that some supplies were missing that were needed to bathe the patient. The lone CNA stepped out of the room to obtain more supplies leaving the patient alone for several minutes.
During the bath the patient did not complain of pain or give any obvious signs of distress. The assistant continued with the bath. When the other assistant returned they took the patient out of the bath and prepared to take her back to her room. At that point the "transporting" nursing assistant noted that the patient's foot was "bleeding." It would turn out that patient's legs were in fact peeling from scalding second degree burned received during the bath.
Both of the CNAs noted and agreed that the patient had been burned. They also discussed that it should be reported to the nurses on duty. The nurse who had given the bath stated a report would be given to the nurse. This was never done.
The other CNA that transported the patient back to the room simply reported to the nurse that the "patient was ready" for the day's dressings/treatments.
When the nurse went in to do the treatments, she noted the patients scalded extremities and immediately reported both the aides. As a result the Department of Health (which issued certifications) was contacted and revoked the licenses of both CNAs.
Their conduct, it stated, was grossly negligent and resulted in serious injury to the patient.
The aides would appeal.
Questions to be answered:
1. Was the accepted standard of care expected of a Certified Nursing Assistant observed by the two persons in their handling of the patient?
2. Was the patient placed in unnecessary jeopardy from the time the injury was noted to the time the nurse discovered the incident.
3. Could the nurses on duty have also been held liable for the actions/inactions of the nursing assistants?
It could be reasonably expected that a nursing assistant would recognize obvious signs of injury such as "bleeding" and "peeling skin." In this case it was noted by the assistant when the patient was taken out of the bath.
The standards of practice would clearly dictate that "any change in condition" be reported to the nurse. In this case, an injury such as a burn where there was clear evidence of tissue damage was should have immediately been reported.
By not reporting the incident at all, the certified nursing assistants delayed treatment the patient's burned extremities. In a patient that already has skin damage, this inaction increased the risk of additional pain, tissue destruction and infection.
Had the incident been reported to the nurse on duty, the burns could have been assessed and treated promptly. Instead, the patient was allowed to "suffer" until discovered by the licensed practical nurse coming in to perform treatments.
The actions of the Certified Nursing Assistants put both the patient and the nurses supervising them in jeopardy.
It is ultimately the responsibility of the nurse, to monitor the safety of the patient. This includes when care is being given by a nursing assistant or other unlicensed assistive personnel under their supervision.
The family of the patient when/if initiating a lawsuit, would be well within their rights to ask:
1. Where was the nurse when the bath was being given.
2. Why wasn't the patient observed or checked on following the bath.
3. What training did the certified nursing assistants have?
It is the responsibility of the Nurse to be sure the assistants working with her patients are competent in their duties. When this is not the case, as soon as it comes to light, a duty is owed to the patient to correct the situation.
Even though the nursing assistants were working with the patient at the time, both they, the nursing staff and the facility could be held accountable to the patient's injuries.
Regardless of corrective actions that are taken, the nurse is still held responsible for any incidents that can occur.
Related Nursing Link Sections:
Care Givers, Nursing Homes & Long Term Care on: The Nurse Friendly
Certified Nursing Assistants, CNA, Nursing & Healthcare Jobs on: The Nurse Friendly
Clinical Charting and Documentation, Nurses Notes:
Medical Legal Consulting Nurse Entrepreneurs:
Related Malpractice Cases:
September 12, 1999: Sleep Apnea Monitor Turned off or Ignored By Nursing Staff, Patient's Coding Goes Unnoticed.
Monitors and Monitored patients present special challenges to practicing nurses. Like a call bell, when alarms on a monitor are activated, they can signal benign or life-threatening events. In this case, a patient's monitors did not alarm as expected. The patient was in distress and would be found without respirations and pulseless by the nurse on duty.
Odom v. State Dept. of Health and Hosp., 322 So. 2d 91 -LA (1999)
August 8, 1999: Pregnant Prison Inmate Complains of Miscarriage,
Corrections Nurse On Duty Ignores Symptoms?
Ferris v. County of Kennebec, 44 5. Supp.2d 62 -ME (1999)
Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care.
August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
July 11, 1999: Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?
Nursing homes are frequently a patient's destination for rehabilitation following surgery. Common conditions fitting this bill include large bone fractures, hip replacements and stroke. Following these acute episodes, the patients are too unstable to go home and not "sick" enough to have their
hospital stays reimbursed by insurance companies. The purpose of admission to a nursing home is to help the patient regain lost function, strength and health. In this case, the patient would remain in the Nursing Home till her death of complications. Lloyd v. County of Du Page, 707 NE.2d 1252 - IL (1999)
June 27, 1999: Elderly Patient Repeatedly Injured In Nursing Home "Accidents." Negligence, Coincidence or Abuse?
As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes. When a family member is placed in a facility, a certain standard of care is expected. In this case, a resident was injured repeatedly while under their care. When the patient died a few days after being "dropped" the family sued.
Brickey v. Concerned Care of Midwest Ince. 988 S.W. 2d 592 MO (1999)
1. 40 RRNL 2 (July 1999)
2. Oklahoma Board of Nursing Guidelines. 1993. "Delegation of Nursing Functions to Unlicensed Persons." Retrieved September 26, 1999 from the World Wide Web:
Other products and companies referred to herein are trademarks or registered trademarks of their
respective companies or mark holders, and are not owned or affiliated with Nursefriendly, Inc. or any of it's affiliated companies.