EVERGREEN WILLOWS

Evergreen Willows, a new convalescent home, had been in operation for several months. The large one-story building, which had been specially constructed for its purpose, was divided into two identical wings, designated A and B wings. In the center of the building, separating the wings, was a large living room, a chapel, offices, and a middle wing which included the kitchen, patients' dining room, and a employees' dining room. Each wing consisted of a nurse's station in the center with a corridor of patients' rooms to each side (see Exhibit 1).
Each nurse's station served the patients for its wing, and each was under the direction of a charge nurse. Other nurses and certified nursing assistants (CNAs, or nurse's aides) worked under the charge nurse. From the opening day, each wing had been staffed separately. The director of nurses had assigned the more experienced older CNAs to "A" wing, where she planned to locate sicker patients. She assigned the less experienced CNAs to "B" wing, which was to have patients who were more ambulatory. Except on rare occasions, A wing staff did not work on B wing, nor did B wing staff work on A wing
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The day shift on B wing consisted of one charge nurse and four CNAs. Normally the charge nurse was Jenny, a young registered nurse (RN) who had not had any previous experience as a charge nurse before working at the home. On her days off, she was replaced by Sue, a licensed practical nurse (LPN) who worked part-time. The CNAs had rotating days off each week, so that, except when someone was sick and had to be replaced, the same CNAs were usually on duty at the same time. The B wing CNAs were of similar age and experience, having been hired at the same time. All lived in the local community and tended to see one another socially after hours.
Jenny's duties as charge nurse included dispensing medications,