For past week Resident has been c/o of shortness of breath (SOB). Treated with prn oxygen and nebulizer treatments. Resident c/o chest pain one day as well as SOB at 9:30 AM. Still treated with O2 and Nebulizer Tx. No call to the DOC. DOC make rounds at 6:30 PM. Nurse gets order to send to ER to be evaluated. Doesn't get sent to ER till 5:30 AM the next morning. Resident dies a few hours later. Resident is a DNR. Nurse tried to call the Responsible Party before shipping to the hospital. Didn't reach RP till 1:00 AM. Nurse getting the order left at 1:30 AM without shipping the resident out. ER records show the resident had elevated troponin levels.
History on the Nurse... Disciplined for not following MD orders 8 months prior to incident.
Disciplined 4 months prior for the same thing this time monitored for a month.
Nurse worked double shifts. At the time of the incident, Nurse had 95 hours of overtime...
yes... 95 hours overtime.
Oncoming nurse was from an agency. Had worked in the facility before.
Is this a case of neglect? Are both Nurses responsible? Is the facility responsible as well?
Jun 5, '03
The first c/o SOB should have been reported to the doc, this was a change in the patient condition. Even if the tx made the assessment WNL. Second, the c/o chest pain should have been reported at the time of the complaint. Then the doc could have made the decision upon to send to ER or not. What was the hold up sending the patient? Nine hrs later the patient left for the ER. Despite the patient's DNR order, the RN was NOT resusitating the patient just maintaining life until that point of arrest.
As far as the RN working 95 hrs of over time....Is this possible?
I think that both the RN & the facility should be investigated for the happenins of that day.
The publc trust the staff at a long term facility to take care of there loved ones, with incidents like this to continue, there will be no trust.
Last edit by HARN on Jun 5, '03