I recently started my nursing career at a nursing home facility. A resident who is usually with the staff at the nurses station, due to her high risk for falls, was placed in restraints by one of the CNAs. This resident is normally very agitated and combative and, unfortunately was uncontrollable the night of the incident. This resident tends to keep the night staff busy the entire shift. I am being accused of being aware that this patient was placed in restraints, but not reporting it. What are my responsibilities as a new grad in this situation, as this patient in question was not assigned to me?
Nancy Brent replies:
Congratulations on your graduation and your first job. Unfortunately, you have experienced what is often a hard-learned principle in a first job. As an RN, you are accountable and responsible for the actions of those in nursing whose position is subordinate to yours. You are the one educated and licensed to provide leadership in the provision of nursing care CNAs work under your supervision and direction and provide patient care if it is delegated to them by you.
Although you stated you were not assigned the patient, it is assumed that the CNA was working under your general direction (since no CNA functions independently without RN supervision), or that you may have assigned this CNA to this patient. So the accountability for the decision to place the resident in restraints is shared. As the RN, you are responsible for your required general oversight or, if care is delegated, for delegating patient care carefully, knowing the person you delegate the care to can provide the nursing care the patient needs. You are responsible for evaluating what was done and reporting a situation, as required, to the appropriate individuals in the facility.
The CNA bears responsibility for providing patient care non-negligently and reporting back to you about any patient care issues that arise. In this case, placing the patient in restraints pursuant to facility policy would be an example of such an issue. If the decision to place a patient in restraints was done without prior approval of an RN or physician, the CNA will bear liability for that conduct.
As you probably know, the use of restraints in long-term care and psychiatric facilities is highly regulated due to abuses that have occurred in the past. State and federal laws require specific steps and reporting when they are used. If you delegated the care of that patient to the CNA when the CNA reported to you and either you requested information about the resident or you knew that the patient was put in restraints you are responsible for reporting the restraint use not only in the resident’s record, but also to those established by policy in the facility.
You may want to discuss how to handle this accusation with a nurse attorney or attorney who can help you defend yourself. It always is important to keep in mind that as an RN, it is you who are responsible for the nursing care of the patients on your unit for the delegation of patient care. Thus, it is the nurse who will be at least one of the persons who defends a patient care decision.
A good reference text for you is the American Nurses Association’s Principles for Delegation (2005). It is available on the ANA website at www.nursingworld.org. It also includes text on law and nursing practice, with a particular emphasis on the principles of professional negligence and liability.