NUR4063 Module 2 delegation and accountability paper example

The Task Moved, the Accountability Did Not: Night Delegation in a Skilled Nursing Facility and a Missed Oxygen Reading

Student Name

American College of Education

NUR4063: Leadership and Management in Healthcare

Module 2 Assignment

Instructor Name

September 14, 2026

The Night in Sequence

On a Tuesday night, a 60-resident skilled nursing facility was staffed by one registered nurse supervisor, two licensed practical nurses who each held a 30-resident hall, and four certified nursing assistants. The facility, the staff and the resident are composites written for this assignment. At 2230, a CNA told the RN supervisor that an 84-year-old resident with dementia and heart failure had a new cough and seemed more tired than usual. The RN was admitting a new resident from the hospital at the time. She asked the hall LPN to recheck the resident's vital signs at 0200 and call her if anything was abnormal.

At 0200, the LPN's recorded values were 37.9 degrees Celsius, 24 breaths a minute and a pulse oximetry reading of 89 percent without supplemental oxygen, and charted that the resident was resting with a moist cough. She did not call the RN. She later explained that the resident's saturation had been 91 percent on admission two months earlier and that she did not think a small drop was worth waking the provider. At 0540, a CNA found the resident breathing rapidly with a saturation of 82 percent. The RN assessed him, called the on-call provider and arranged a transfer, and the resident was admitted to the hospital with pneumonia and acute decompensated heart failure.

The question for this paper is not who made a mistake, since several people did, but where accountability sat at each step and what the facility should change so that the next resident with a new cough is assessed in time.

What Was Delegated and What Could Not Be

The national delegation guidelines distinguish between assigning work within another licensed nurse's scope and delegating a task that falls within the delegating nurse's own responsibilities, and they emphasize that the licensed nurse who delegates remains accountable for the decision to delegate and for supervising the outcome (National Council of State Boards of Nursing [NCSBN], 2016). In most states, an LPN may collect data, including vital signs and focused observations, and contribute to the assessment, while the comprehensive assessment of a change in condition and the judgment about what it means belong to the registered nurse.

By that standard, asking the LPN to recheck vital signs at 0200 was an appropriate request. What the RN could not hand over was the assessment of a resident with a new change in condition, and her instruction, call me if anything is abnormal, quietly transferred that judgment to the LPN by leaving the definition of abnormal to her. Delegation failed not when the task moved, but when the threshold for escalation stayed in the RN's head. A clearer instruction would have named specific values: call if the temperature is 37.8 or higher, the respiratory rate is 22 or higher or the saturation is below 92 percent, and I will come assess him either way before 0300.

The RN also did not close the loop. Having delegated a check on a resident with a new cough and a history of heart failure, she did not return to see him or ask the LPN for the 0200 values. The guidelines treat supervision and follow-up as part of delegation, not an optional addition.

Delegation in Long-Term Care Is Different

The hospital version of delegation, with an RN assigned to five or six patients and a charge nurse nearby, does not describe this facility. One RN supervised sixty residents, most of the direct licensed care was provided by LPNs, and the RN spent the first two hours of the shift on an admission. Corazzini et al. (2010) studied delegation in long-term care and found that the boundaries between RN and LPN practice were often defined in practice by job descriptions and facility routines rather than by scope of practice, and that LPNs in these settings frequently carried responsibilities, including assessment of residents, that blurred those boundaries.

That finding helps explain the LPN's decision. In a facility where LPNs routinely decide whether a change in a resident is significant enough to report, she was doing what the facility's routine expected, even though the change she saw needed an RN's assessment. The RN's instruction reflected the same routine. When scope is defined by habit rather than by law, the gap between the two tends to be discovered at 0540.

A Just Culture Reading

Marx (2001) proposed that organizations respond to errors by distinguishing among human error, which is an inadvertent slip and calls for consoling the person and fixing the system; at-risk behavior, where a person chooses a shortcut without seeing its danger or believes the danger is justified, which calls for coaching; and reckless behavior, where a person knowingly ignores a serious and unjustified danger, which may warrant discipline. The framework is useful here because it prevents both easy answers: blaming the LPN alone and excusing everyone because the system was stretched.

The LPN's decision not to report an oxygen saturation of 89 percent with a fever and rapid breathing is best described as at-risk behavior. She made a choice, based on a comparison with an old baseline, and did not recognize the risk. She was not reckless, and she needs coaching and clearer thresholds rather than punishment. The RN's vague instruction and missing follow-up are also at-risk behavior: choices shaped by an admission in progress and a facility routine that had normalized LPN judgment about changes in condition. The system contributed as well, through a staffing pattern that left one RN responsible for sixty residents and an admission at the same time, and through the absence of a standard change-in-condition tool with defined reporting values.

Changes at the Person and System Level

For the RN, the change is in how she delegates. Every delegated check on a resident with a new change in condition will include written reporting thresholds and a time by which she will see the resident herself, and she will ask for the values at the time they are due rather than waiting to be called. For the LPN, coaching will focus on comparing a change against the resident's recent baseline rather than an admission value and on the facility's expectation that any new respiratory symptom with an abnormal vital sign is reported to the RN.

For the facility, the director of nursing will adopt a standard change-in-condition communication tool with defined vital sign triggers for LPNs and CNAs, so that the threshold no longer depends on individual judgment at 0200. The facility will also review its admission practices so that the night RN supervisor does not complete a full admission during the first hours of the shift without another licensed nurse covering her supervisory role. Each change will be checked after three months by reviewing every transfer to the hospital for whether a change in condition was documented and reported before the transfer.

Conclusion

The RN supervisor in this case delegated an appropriate task, a vital signs check, and in doing so handed over a judgment that was hers to make. The LPN, working within a facility routine that blurred the line between data collection and assessment, did not report findings that called for an RN's attention. Accountability for the delegation, the instruction and the follow-up stayed with the RN throughout, even though the task had moved. Seeing the failure through a just culture lens turns the case from a question of fault into a set of changes that protect the next resident, which is the purpose of holding anyone accountable in the first place.

References

Corazzini, K. N., Anderson, R. A., Rapp, C. G., Mueller, C., McConnell, E. S., & Lekan, D. (2010). Delegation in long-term care: Scope of practice or job description? OJIN: The Online Journal of Issues in Nursing, 15(2), Manuscript 4. https://doi.org/10.3912/OJIN.Vol15No02Man04

Marx, D. (2001). Patient safety and the "just culture": A primer for health care executives. Trustees of Columbia University.

National Council of State Boards of Nursing. (2016). National guidelines for nursing delegation. Journal of Nursing Regulation, 7(1), 5-14. https://doi.org/10.1016/S2155-8256(16)31035-3