I work in a hospital and my best friend who works as a home visiting nurse was recently telling me about something he had heard about in his workplace.
A nurse went to visit a patient at home and they did not answer their door, the door was unlocked so the nurse went in to check on them. The nurse found the patient lying there who was not able to respond in words.
The nurse left the home because they did not feel comfortable in the situation and contacted their manager for advice. The manager told them to call the patient on their phone, but there was no answer.
The manager told the nurse that they would organize for another nurse to go along with them at a later time.
The 2 nurses went together to see the patient and called an ambulance.
Many of my patients I see in home (in fact all of them, actually) have told me not to knock (I do the first time) and just to come in. They know when (approximately) to expect me. If I would go in and find one of them down I would follow CPR protocol (establish pulselessness/breathlessness and call 911, etc. if appropriate.) I of course know their CPR status. If they are a DNR/CCA and have arrested, I would follow their wishes.
This sounds tooooo much like a hypothetical school assignment for an entry level Practice of Nursing class (where else would you hear 'duty of care' fro a new poster like OP?).
And too much ambiguity makes this all too questionable. Altho I do like OP Wuzzie's take on the possibility of some legal fishing.
If the nurse, in the performance of their job, came across a patient who was clearly in distress (as evidenced by the altered mental status and low GCS) and did nothing more than leave the patient and call their supervisor, that nurse is guilty of abandonment, failure-to-rescue, and gross negligence.
1. Unless the patient and I had previously established that I could enter his home without knocking, I would not have entered the home. When I was a visiting nurse, if the patient didn't answer the door after I knocked or rang the bell several times, my next step would be to try to call them. If they did not answer the phone, I would leave a message asking if they wanted me to come back at another time (though in my experience people who were not home at an agreed upon time or who were home and chose not to answer the door either did not have their voicemail box set up or if it was set up it was full). Depending on what I was seeing the patient for, I would notify the MD either then or later in the day. For example, if it was an oncology patient and the clinic was expecting labs, I'd call and say "FYI, I couldn't see Sarah Smith this morning. No one answered the door and Mom didn't answer the phone when I called." The clinic nurse would either then inform me that the child had been admitted to the hospital, was in clinic for a sick visit or that they would reach out to Mom and tell her that they needed to come to clinic since they weren't home for the visiting nurse. If it was just a kid I was seeing for weight checks or something routine, I'd call the MD's office later in the day. Then I'd document that the patient was not home not found and continue with my day.
2. In the given situation, since the nurse entered the home and found the patient unresponsive, she had a duty to act and should have called 911 right then and there, unless the patient was a known DNR, in which case she should have called the emergency contact she had for him.
A lot of what you would do in the situation of the patient not answering the door depends on the history with the patient. My patients were children so I generally didn't have a reason to suspect that if they didn't answer the door it was because they were helpless/unconscious/etc in the home. I did have a patient at my current job whose Mom overdosed on heroin about a year ago and a family member found the children unsupervised in soiled diapers a couple days later. That family member knew Mom's history though and had a reason to be suspicious when she couldn't reach her for several days. I also once had a patient who was found to be septic after his mother (from across the country) called the police to do a welfare check on him when she couldn't reach him. But he had a complex heart history and had complained of feeling unwell the last time she talked to him, so she had reason to be concerned. If there was any such question with the patient in the OP, as a visiting nurse, I may have called 911 for a wellness check when the patient didn't answer the door.
This sounds tooooo much like a hypothetical school assignment for an entry level Practice of Nursing class (where else would you hear 'duty of care' fro a new poster like OP?).
And too much ambiguity makes this all too questionable. Altho I do like OP Wuzzie's take on the possibility of some legal fishing.
Hi amoLucia,
I do not think you should assume that because I am a first time poster on this forum, then that also means that I am new to nursing.
When my best friend told me of this situation which occurred in his workplace, I was actually quite shocked with what he told me. My best friend is absolutely devastated that this patient had passed away and was questioning whether or not an earlier response by both the nurse who visited as well as the manager giving advice may have resulted in the patient still being alive today.
And thus, the reason for my post - to see how others from a wide spectrum of levels of experience - would have reacted in the situation.
From what my friend told me, the manager giving advice as well as the nurse who visited were quite junior, and inexperience may have largely contributed to this situation, it has made me question - where do we as nurses stand in respect to duty of care? Does being a junior nurse or manager with limited experience excuse them from their duty of care? And what would other nurses do in this situation?
I know what I would have done in this situation as it has always been drilled into me that in these situations that you NEVER leave the patient and my immediate response would be to call an ambulance. I would have also expected the manager to tell the nurse to call an ambulance.
As a visiting nurse, my agency policy would be to call 911 immediately and stay with the patient until they arrived. I would call the supervisor as soon as I finished calling 911, to update them. The delay in response may or may not have contributed to the subsequent death, but I cannot imagine a nurse just leaving a patient in that condition.
Yes, it has always been drilled into me that we never leave a patient in a scenario like this. And I am also surprised about the advice which was given by the manager.
1. Unless the patient and I had previously established that I could enter his home without knocking, I would not have entered the home. When I was a visiting nurse, if the patient didn't answer the door after I knocked or rang the bell several times, my next step would be to try to call them. If they did not answer the phone, I would leave a message asking if they wanted me to come back at another time (though in my experience people who were not home at an agreed upon time or who were home and chose not to answer the door either did not have their voicemail box set up or if it was set up it was full). Depending on what I was seeing the patient for, I would notify the MD either then or later in the day. For example, if it was an oncology patient and the clinic was expecting labs, I'd call and say "FYI, I couldn't see Sarah Smith this morning. No one answered the door and Mom didn't answer the phone when I called." The clinic nurse would either then inform me that the child had been admitted to the hospital, was in clinic for a sick visit or that they would reach out to Mom and tell her that they needed to come to clinic since they weren't home for the visiting nurse. If it was just a kid I was seeing for weight checks or something routine, I'd call the MD's office later in the day. Then I'd document that the patient was not home not found and continue with my day.
2. In the given situation, since the nurse entered the home and found the patient unresponsive, she had a duty to act and should have called 911 right then and there, unless the patient was a known DNR, in which case she should have called the emergency contact she had for him.
A lot of what you would do in the situation of the patient not answering the door depends on the history with the patient. My patients were children so I generally didn't have a reason to suspect that if they didn't answer the door it was because they were helpless/unconscious/etc in the home. I did have a patient at my current job whose Mom overdosed on heroin about a year ago and a family member found the children unsupervised in soiled diapers a couple days later. That family member knew Mom's history though and had a reason to be suspicious when she couldn't reach her for several days. I also once had a patient who was found to be septic after his mother (from across the country) called the police to do a welfare check on him when she couldn't reach him. But he had a complex heart history and had complained of feeling unwell the last time she talked to him, so she had reason to be concerned. If there was any such question with the patient in the OP, as a visiting nurse, I may have called 911 for a wellness check when the patient didn't answer the door.
Hi KelRN215.
The nurse who visited the patient was familiar with the patient and has visited this patient many times in the past. The patient normally left the door open for the nurses and because the patient didnt answer the door they became concerned and entered the home on finding that the door was unlocked and found the patient with reduced GCS.
My best friend told me the reason that the nurse left the premises was because they felt 'uncomfortable' - and my best friend did not know what that actually meant - I guess that would need to be further explored.
Based on the limited info provided, I would have stayed with the patient, called 911, and waited with them until help arrived while taking vital info to pass onto the paramedics.
However, there is a lot of missing info here, so it's not really fair of us to judge that RN for making the call they did.
Hi Union-Jack,
Thanks for your reply, I am not asking you to judge the RN for the call which they made.
I am just wanting to know what other people would do in this situation if they were confronted with it. I should have worded my initial post better.
The nurse who visited the patient was familiar with the patient and has visited this patient many times in the past. The patient normally left the door open for the nurses and because the patient didnt answer the door they became concerned and entered the home on finding that the door was unlocked and found the patient with reduced GCS.
My best friend told me the reason that the nurse left the premises was because they felt 'uncomfortable' - and my best friend did not know what that actually meant - I guess that would need to be further explored.
In that situation, any prudent nurse would call 911 unless, as stated previously, the patient was known to be a DNR. If the patient was back to baseline by the time EMS arrived, he could refuse the transport. I had a few regular patients when I was a visiting nurse who told me to just enter their homes/not to knock and it sounds like that was established in this case.
ETA- if, as a manager, I received a call from a nurse who said "I entered my patient's home and he is unresponsive, what do I do?" my reaction would be "why on earth are you calling me and not 911?" 911 first then notify the agency of what occurred.
The first nurse is guilty of patient abandonment unless the patient was a known DNR but I still would have called their contact number(s)
If the patient was not a DNR I would first call their contact (daughter/son/POA, etc) if no answer I would go ahead and call the ambulance.
The manager is incompetent. My manager would NEVER EVER tell me to leave and send two other nurses at a later time!
Thanks for your reply JerseyBSN.
The patient did not have a DNR order in place. I, like you, was also surprised hat the manager did not direct the nurse to call an ambulance, but instead organised for 2 nurses to go together at a later time.
In that situation, any prudent nurse would call 911 unless, as stated previously, the patient was known to be a DNR. If the patient was back to baseline by the time EMS arrived, he could refuse the transport. I had a few regular patients when I was a visiting nurse who told me to just enter their homes/not to knock and it sounds like that was established in this case.
ETA- if, as a manager, I received a call from a nurse who said "I entered my patient's home and he is unresponsive, what do I do?" my reaction would be "why on earth are you calling me and not 911?" 911 first then notify the agency of what occurred.
Absolutely agree with you KelRN215 and thanks for taking the time to respond (as well as everyone else who has responded). Patient did not have a DNR order in place.
From what my friend told me, the nurse who attended as well as the manager who gave advice are quite junior in their roles.
But, does that excuse them from their duty of care?
My initial reaction would be to call an ambulance as is my best friends. My best friend is extremely upset about the situation, would an earlier response by the nurse who visited and their manager mean that the patient would still be alive today? That, we cannot be certain of, but there is a possibility that they may have still been alive..
One thing the original poster didn't note was if this was a first visit, and what the patient's baseline was. Is the patient normally non-verbal, does the patient normally lay in bed? Was there supposed to be family at the home? But yes, if in doubt call 911.
Edited to add--I would call 911 even if the patient is a DNR. DNR does not mean do not treat. They could have had an infection, etc, that can be treated with antibiotics! I wouldn't have called if they were *hospice* and expected to pass, but other then that, yes, call!
LadysSolo
411 Posts
Many of my patients I see in home (in fact all of them, actually) have told me not to knock (I do the first time) and just to come in. They know when (approximately) to expect me. If I would go in and find one of them down I would follow CPR protocol (establish pulselessness/breathlessness and call 911, etc. if appropriate.) I of course know their CPR status. If they are a DNR/CCA and have arrested, I would follow their wishes.