Nancy, a registered nurse, has recorded a telephone order from the attending physician to administer one unit of blood to Baby Robby, a pediatric patient. She delegates this order to a licensed professional nurse whose name is Kelly. Kelly has been with the hospital for several years and has just graduated LPN school. Kelly is known among the nurses as an assistant and unit secretary for many years and she is considered a very trustworthy nurse. Kelly also just finished an IV certification class but claims that she will document it on Monday since Human resources is not open, it being a weekend. Nancy sends Kelly to get the unit from the blood bank, hang the blood with saline and then administer it. After one hour it is time for the charge nurse to give report, she sends Kelly in to get the first set of vital signs and check on Robby. Since Nancy is also the charge nurse, she finds herself a little behind, so she has Kelly write a short note in the record and a set of vital signs. When Kelly checks on the patient she finds that Robby is lethargic and she immediately reports this to Nancy who then declares that she needs to write an incident report up and once she is finished giving report she does exactly that and then writes in the chart that an incident report has been filed with all the relevant facts listed. She then clocks out with the knowledge that she finished everything that needed to be done.
a. possibly something forgotten
b. a violation of standard of practice
c. a legal mishap
d. an ethical violation
e. a delegation problem
f. or some other problem