Nurse Leader Case Study: Failure to perform Director of Nursing duties in a competent manner

A State Board of Nursing (SBON) complaint can be filed against a nurse by a patient, resident, colleague, employer, and/or regulatory agency.

Complaints are subsequently investigated by the SBON, with results ranging from no action against the nurse to revocation of the license to practice nursing. This case study involves a registered nurse, employed as the Director of Nursing (DON) at a rehabilitation/skilled nursing facility.


The resident in this matter was a male in his 90s who was admitted to the rehabilitation/skilled nursing facility (“the facility”) to undergo physical therapy following surgery for a right hip fracture. Upon admission, the admitting nurse noted that the resident could not ambulate, had a deep tissue injury on his sacrum and had blanchable redness on both heels. An intervention of heel protectors and elevation was noted on his plan of care. However, there were not enough staff to perform essential nursing tasks at the facility, so staff nurses and care attendants did not typically have enough time to review residents’ care plans or treatment notes. Therefore, the suggested interventions were not added to the resident’s treatment flowsheet and his heel condition was not specifically monitored by the nurses on staff.

The facility had a treatment nurse who was responsible for wound care. That wound care nurse was on leave while the resident was at the facility. The DON (the insured registered nurse) was responsible for staff assignments, facility policies and procedures, and the overall operation of the nursing team. The LPN who the DON assigned as the wound care nurses’ replacement was not properly trained on wound care, which the DON should have noted prior to assigning them to that role. Because the resident’s wounds were not treated properly, the resident’s pressure injuries to his heels worsened during his time at the facility.

In addition, the resident also experienced significant weight loss while at the facility- 12 pounds over the course of 27 days. According to the facility’s policy and procedure, significant weight changes (≥ 3 pounds within one week) were to be noted in the healthcare information record, reported to the unit charge nurse or DON, and communicated to the resident’s family and physician in a timely manner. However, facility policy did not indicate who was ultimately responsible for this reporting. The DON assessed the resident and reviewed his chart on day 18 of his stay after being notified about his significant weight change. Neither the resident’s family nor his physician were notified about the resident’s weight changes or pressure ulcers until he was discharged to the hospital nine days later.

In this matter, the resident had been admitted to the facility for 27 days. During that time, he lost 12 pounds and developed Stage III bilateral pressure injuries to both heels and progressive hyponatremia, which required additional hospitalization and home care.

Risk Management Comments

Based upon a complaint about the resident’s care, the Department of Health (DOH) conducted a survey of the facility and issued a report. The report found several deficiencies, including:

  • Failure to ensure proper treatment/services to prevent pressure injuries.
  • Failure to ensure proper nutritional status and sufficient fluid intake, contributing to tissue breakdown.
  • Failure to maintain proper clinical records on each resident.
  • Failure to maintain accurate pressure injury documentation.

The facility was issued a citation by the DOH, which the facility did not appeal.
Based upon the resident’s care at the facility, a medical malpractice suit was filed against the facility, which led to an award of $750,000 to the resident. While none of the malpractice award was attributed specifically to the insured DON, a report of the payment was made to the SBON. The report led to an investigation into the care the resident received at the facility. Ultimately, the SBON investigated the practices of the DON as well as two other nurses at the facility. Allegations against the DON included:

  • Failure to perform nursing duties in a competent manner (incompetence).
  • Unprofessional conduct.

The SBON’s investigation into the facility and the actions of the DON concluded that the DON performed her duties in an incompetent manner, as defined by the state practice act. The investigation revealed that the delineation of duties and assignments was not clear, even regarding those in charge of nursing care for each shift. For example, nursing supervisors managing the nursing staff at the facility, the shift supervisors and charge nurses, were not fully conversant with policies for transferring information from the incoming resident’s care plans to their treatment flowsheets. Therefore, basic nursing functions were not adequately outlined and supervised.

Moreover, while the nursing staff at the facility attested to investigators that they were familiar with the standards of nursing practice, they were unclear about the logistics of how those standards should be put into practice at the facility. Staff policies were not adequately outlined for nursing staff to know and understand their responsibilities for each shift. The SBON also determined that the facility lacking sufficient staff to perform essential nursing tasks. Staff nurses admitted to SBON investigators that they typically did not have the time to review the residents’ care plan history or progress notes unless the residents were deemed “high risk”. The SBON expressed that the responsibility for safe staffing levels was imposed upon the DON, especially since the DON never formally notified facility administrators about staffing concerns endangering resident welfare.


The SBON concluded that the deficiencies noted in the resident’s care pointed to a leadership issue. The DON had the authority and responsibility to ensure that the overall operation of the nursing team at the facility complied with regulations and standards governing resident care. The SBON further concluded that the DON failed to create, disseminate, and educate nursing staff on the policies for which she had oversight, which led to the resident’s facility-acquired injury. The SBON noted that a competent and prudent nurse in the same position would assure that the facility was adequately staffed, and that the nursing staff at the facility had clear policies outlining standard workflow and care requirements.

The SBON placed the DON on probation for three years, concluding that the SBON’s incompetence in her role put residents at risk. The SBON matter took almost a year to resolve, and expenses incurred to defend the insured nurse in this matter exceeded $1,800.*

Risk Control Recommendations

The following strategies can help nurse leaders and managers enhance quality of care and resident/patient satisfaction, while reducing the likelihood of medical malpractice claims and SBON actions:

  • Serve as the residents’/patients’ advocate in ensuring resident/patient safety and the quality of care delivered.
  • If policies and procedures are outdated, unclear, or absent, update, clarify, or initiate the policy, working with the appropriate individual(s) or committee(s).
  • Supervise nursing staff and monitor their needs. Ensure that nursing practice is safe, effective, efficient, equitable, timely, and resident/patient centered. Anticipate potential patient care problems before they arise.
  • Clearly articulate the roles and responsibilities of the nursing staff within the team. Open communication with nursing staff regarding how they each view their roles and responsibilities can help to clarify and identify gaps in roles and responsibilities.
  • Communicate effectively in all areas of practice. Effective communication can help to manage change and address conflict. Nurse leaders/managers must be competent in making expeditious decisions, evaluating the quality of resident/patient care and resolving conflicts.
  • Be aware of and document staff member knowledge, skills, and competencies, as well as whether they are maintaining their competencies. Provide staff nurses with the educational and clinical opportunities necessary to support optimal patient care.
  • Respond promptly to all allegations of incompetent or questionable care, whether initiated by residents/patients or staff. Thoroughly investigate allegations, recommend options for correction, and follow up on recommended actions. Include follow-up evaluations in nurses’ performance records, documenting that the nurses are competent to care for residents/patients within clinical settings.
  • Alert hospital/facility administrators and upper level managers of staffing concerns after taking all necessary actions within the control of the nurse leader/manager in order to ameliorate the circumstances, such as approving overtime or reassigning personnel. Notify the chief operating officer when understaffing endangers patient welfare, either directly or through formal communication channels.

*Monetary amounts represent the legal expenses paid solely on behalf of the insured registered nurse.

The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. Please note that Internet hyperlinks cited herein are active as of the date of publication, but may be subject to change or discontinuation. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. Use of the term “partnership” and/or “partner” should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2021 CNA. All rights reserved.
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