RN #3 clocked in at 6:59 p.m. for her scheduled shift on September 24th at Norfolk Health Care Center's second-floor tracheostomy unit. She clocked out at 8:47 p.m., handing over the keys and walking away from patients who required round-the-clock specialized care.
The nurse was scheduled to care for Resident #190, a patient in a chronic vegetative state with a tracheostomy tube and feeding tube who was completely dependent on staff for survival. The resident had been admitted with acute encephalopathy, end-stage renal failure requiring dialysis, anoxic brain damage, and chronic respiratory failure.
When inspectors interviewed RN #3 the next morning, she explained her decision to abandon her patients. "She stated that after clocking in, she heard the staff discussing the people who had called out, including the RN supervisor," according to the federal inspection report. The nurse realized she would be the only registered nurse on the specialized unit.
"She stated that she suddenly realized she would be the only RN on the specialized tracheostomy unit responsible for the entire unit, which she had never worked before, and as a new nurse, she had not had much experience with tracheostomies."
The nurse called her supervisor, who then contacted the Director of Nursing. Both refused to come to the facility.
"She stated that at that point, she was worried about what could happen if something went wrong. She stated that she did not feel comfortable taking the assignment, so she handed the keys over, clocked out, and went home."
Federal regulations require registered nurse coverage on specialized tracheostomy units because patients with breathing tubes face life-threatening complications that only RNs are trained to handle. Licensed practical nurses cannot provide the same level of assessment and intervention.
Resident #190 was found dead with no registered nurse present on the unit. An RN from another floor had to be summoned to pronounce the death, as only LPNs were working the specialized unit when the discovery was made.
The facility's own records confirmed the Director of Nursing's refusal to respond to the staffing crisis. The DON received a corrective action form stating: "On [the night in question], you failed to ensure there was adequate nurse coverage after being informed of the callouts on the unit. You were also instructed that a member from the nursing leadership needed to come into the center, and no one did."
This was RN #3's first scheduled night working independently on the tracheostomy unit. She described herself as "still in training" and "a new employee at the facility." Despite her inexperience, she was the only registered nurse assigned to care for patients with complex respiratory needs.
The Administrator confirmed to inspectors that she was aware registered nurse coverage was required on all shifts for the specialized tracheostomy unit. She was notified of the concerns during an end-of-day meeting but provided no additional information about how the facility planned to prevent similar abandonment of critically ill patients.
Tracheostomy patients like Resident #190 require constant monitoring for potentially fatal complications including tube displacement, mucus plugs blocking airflow, and respiratory distress. These emergencies demand immediate intervention by nurses trained in advanced airway management.
The inspection report does not indicate whether Resident #190's death was related to the absence of registered nurse coverage. However, federal investigators classified the violation as "immediate jeopardy to resident health or safety," the most serious level of deficiency that can trigger facility closure.
The facility operates a specialized unit specifically for patients with tracheostomies, breathing tubes surgically placed through the neck to bypass upper airway obstructions. These patients often cannot speak and depend entirely on staff to recognize signs of respiratory distress.
Multiple staff members had called out sick that evening, creating the staffing shortage that prompted RN #3's panic. The facility's contingency planning proved inadequate when both the supervisor and Director of Nursing refused to cover the shift or arrange alternative coverage.
RN #3's decision to abandon her patients after discovering she lacked experience highlights broader problems with facility staffing practices. New nurses were apparently assigned to specialized units without adequate preparation or backup support.
The timing of the nurse's departure, less than two hours into her shift, left the tracheostomy unit without required coverage for the entire night. LPNs cannot legally perform many of the assessments and interventions that RN-dependent patients require.
Federal inspectors found that when Resident #190 was discovered dead, no registered nurse was present to provide immediate assessment or attempt resuscitation measures. The facility had to call an RN from another floor simply to officially pronounce the death.
The corrective action issued to the Director of Nursing suggests this was not an isolated incident of inadequate response to staffing crises. The formal discipline indicates facility leadership was aware of their obligations but chose not to fulfill them.
Resident #190 had been receiving palliative care and was designated "Do Not Resuscitate," but still required the specialized monitoring that only registered nurses can provide. The patient's multiple complex conditions, including chronic respiratory failure and dependence on dialysis, made continuous professional assessment essential.
The facility's Administrator acknowledged knowing that RN coverage was mandatory for the tracheostomy unit but took no action when informed of the crisis. This represents a systemic failure of leadership accountability for patient safety.
The inspection occurred following a complaint, suggesting someone reported concerns about the facility's handling of the incident. Federal investigators classified their findings as affecting "few" residents, but the immediate jeopardy designation indicates the violations posed serious risk of death or severe harm.
RN #3 remains employed at facilities caring for vulnerable patients, despite abandoning critically ill individuals when they needed her most. Her admission that she "did not feel comfortable taking the assignment" raises questions about how facilities assess nurse competency before making critical care assignments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Norfolk Health Care Center from 2025-09-24 including all violations, facility responses, and corrective action plans.