Nurse Case Study: Wrongful delegation of patient care to unlicensed assistive personnel

Our insured was a registered nurse (RN) employed by a home healthcare agency. She was with a patient when she received a telephone call from a certified nursing assistant (CNA) who was employed at the same agency.

The CNA was at the home of a mutual patient and reported that her gastrointestinal (GI) tube had come out sometime during the night. The RN informed the CNA that the patient would need to go to the emergency department to have the tube re-inserted as it would be several hours before she could see the patient. The patient’s family didn’t want to take the patient to the emergency department but would instead wait for the RN to see the patient.

The CNA informed the RN that she had re-inserted several GI tubes when she was employed at a nursing home, so felt comfortable re-inserting this patient’s tube. The RN agreed to let the CNA insert the tube but advised her to not restart the feedings. 

Approximately 45 minutes later, the CNA contacted the RN and affirmed that tube was re-inserted without difficulty and proper placement was confirmed. 

When the nurse arrived at the patient’s home several hours later, she noticed that the patient was receiving tube feeding. When questioned, the daughter confirmed that she resumed the tube feedings shortly after the CNA left and denied being told to wait. The RN noted that the patient was complaining of abdominal pain and reported feeling nauseous.

On physical assessment, the patient’s abdomen was distended and positive for pain with abdominal palpation. After stopping the feeding, the nurse called 911 and the patient was transferred to the nearest hospital where she was diagnosed with peritonitis due to the GI tube being accidentally placed in the peritoneal space.

The family filed a lawsuit against the RN and the home healthcare agency.

The allegations against the RN included:
  • Wrongful delegation of patient care to unlicensed assistive personnel (e.g. CNA);
  • Failure to follow the agency’s policies and procedures on proper delegation, GI tube insertion and supervision of unlicensed assistive personnel;
  • Failure to contact the referring provider and obtain an order to reinsert the GI tube; and 
  • Failure to assure that the patient and family had received appropriate communication related to re-inserting the GI tube and holding the GI feedings.


A settlement was reached prior to a lawsuit going to trial. As mandated by state law, the nurse was also reported to the National Practitioner Data Bank (NPDB).  

The total incurred to defend and settle this case on behalf of our insured nurse exceeded $255,000.

Risk Control Recommendations

  • Know your employer’s policies and procedures related to clinical practices and delegation.  Unfamiliarity to established policies and protocols is not a defense, especially if a clinician has acknowledged receiving education on such policies and protocols. 
  • Prior to delegating tasks, be aware of the knowledge and skills, training, diversity awareness, and experience of the individual to whom you are delegating elements of care. Use good clinical judgement, which includes the complexity of the patient, the availability and competence of the unlicensed assistive personnel, prior to delegating patient care. 
  • Monitor implementation of the delegated task, as appropriate, to the overall patient plan of care. 
  • Evaluate overall condition of the healthcare consumer and the consumer’s response to the delegated task.
  • Evaluate the unlicensed assistive personnel skills and performance of tasks and provide feedback for improvement if needed.
  • For more information regarding nursing delegation, it is recommended that nursing professionals review the  NCSBN and American Nurses Association (ANA) National Guidelines for Nursing Delegation
  • Contact the risk management department, or the legal department of your organization regarding patient or practice issues.

#Best Practices #Case Study #Nurses

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