This past week has been a very difficult one for my family and me, and I thought I would enlist the help of all you wonderful and wise nurses out there. I'm in need of a little guidance.
Just a little background: my uncle was 57, and he had down's syndrome. He has been in group homes most of his life, and was pretty functional until about two years ago. He started to decline cognitively, and then physically. My mother moved him to a SNF closer to us in Dallas a few months ago, so that we could visit him and monitor him a little more closely, since he didn't get the best care in the small town SNF he was in. At the time of the move, he was pretty much debilitated d/t contractures he developed at the last place he was in, had multiple decubitus ulcers, had a peg tube, and was septic. The SNF we moved him notified us immediately that they were transferring him to a hospital nearby. He improved after a couple of weeks and went back to the SNF. My mother was very involved in his care, and was generally notified if anything was changing. The past couple of weeks she had not gotten a chance to visit, but got report from other relatives that he was doing well. On Thanksgiving, however, things took a turn for the worse. He was found at about 0300 by a CNA, with vomit on himself and shallow breathing. When the nurse came in, he had stopped breathing altogether and was sent by EMS to a hospital nearby. He died at 0413, and the nursing home was notified at 0423 of the death. I'm guessing he aspirated, though we will not know for certain what the COD was until the autopsy results are back.
Now, this is where it gets bad. When he was transferred to the ED, no one in my family was notified. The hospital did not receive next of kin information from the SNF when he was sent. When the hospital pronounced him, notified the SNF, and requested more information on him, someone said they would have the nurse call... no one ever did. At 0715 on Thanksgiving, my mother received a phone call from a nurse, who didn't even have the right name, to notify my mother of the death. My uncle died alone in the ED on Thanksgiving, and was sent to the morgue. When I cried and screamed and asked why no one even called to tell us he was being rushed to the ED, all she could say was "Sorry." No explanation. After we gathered my grandmother and my other uncle together to go see him, he had already gone to the ME's office for autopsy. We never even got the chance to say goodbye. My mother can't afford to have a viering and a burial, so we are doing cremation-- she still hasn't seen her brother, never got to hold his hand, and will only be able to see him through a window before he gets turned to ash. We got a call at 10 pm that same day from another nurse, who sent her condolensces, but still could not offer an explantion.
There is no explanation. There is no excuse. There is no reason on this green earth that my family should not have been notified that he stopped breathing and was en route to the ED. There's no reason the ED should not have been given next of kin info. There's no reason that the woman who notified us could not get his name straight before she called to tell us he was dead. There's no reason that she asked to put me on hold to get another line while I cried and asked for answers. There's no reason that our last chance to see and hold him was so horrible taken away from us.
Needless to say, we are furious and hurt. This was a complete miscarriage of trust in a facility that was supposed to care for my uncle. We understand that people fall ill and can die suddenly, and without warning. Obviously we are upset about the death, but more than that is the break in communication that followed. I just needed to see who I should report this to, and what actions I can take. I'm not looking for retribution, though disciplinary actions is most definitely warranted. Nothing is going to give us that time back, but I want to make sure that this doesn't happen to another family.
No, it was not like this. It was most definitely a case of improper procedure.
Yes, sorry, I must have posted before reading your latest posts. I hope the facility has already put the new procedures in place so this doesn't happen to anyone else.
Your grief and bewilderment comes through very strongly in your writing. I'm so sorry this happened.
Yes, sorry, I must have posted before reading your latest posts. I hope the facility has already put the new procedures in place so this doesn't happen to anyone else.
Your grief and bewilderment comes through very strongly in your writing. I'm so sorry this happened.
There is nothing you can do to prevent it from happening again. Your family should have been notified and was not because protocol broke down. It is not the first and won't be the last time that a sad error was made.
If it is of any comfort, your uncle died at 0300, in the nursing home, and no notifications would have permitted anyone to say goodbye or give him a kiss.
I am sorry for your loss.
Thank you very much. I know that he was dead before he got to the ED, but in my family and culture it is important to be with your loved one at the time of death. A dead body is not just a corpse to the people who love him.
We spoke with the DON, and we got those. Knowing that the facility knows they had a deficiency in their procedure will hopefully change the way they operate, and our experience would not have been in vain.
Ok, time to let it go....Use it in your nursing experience to be the nurse who never does anything wrong or makes mistakes or has a crazy, out of control day... good luck!!
There isn't a need for negativity or sarcasm. You can learn from every experience in your life, and I intend to learn from this one. Again, thank you to everyone for your kind words and advice.
Thank you very much. I know that he was dead before he got to the ED, but in my family and culture it is important to be with your loved one at the time of death. A dead body is not just a corpse to the people who love him.
Nor is a dead body just a corpse in mine, and to be with a loved one at the time of death is a universal desire, pretty much. However, you spoke of your sadness that he was alone when he died. You further stated that you want to insure that this never happens again. You cannot.
And I am truly sorry for your loss. However, in your grief you are lashing out and contradicting yourself. You say in one post that you want retribution, in another that you do not.
If you want to vent then vent. But let it be a vent.
Nor is a dead body just a corpse in mine, and to be with a loved one at the time of death is a universal desire, pretty much. However, you spoke of your sadness that he was alone when he died. You further stated that you want to insure that this never happens again. You cannot.
And I am truly sorry for your loss. However, in your grief you are lashing out and contradicting yourself. You say in one post that you want retribution, in another that you do not.
If you want to vent then vent. But let it be a vent.
I'm sorry that you think that I am lashing out, and if it sounds like that, I apologize. That is not my intention...I know that I cannot ever guarantee that it doesn't happen again, but if meeting with administration can help iron out some procedures in a new facility, I am glad that we can do that. I said in my original post that I did NOT want retribution...and I repeated it in a reply, that I am not looking to get anyone in trouble. Retribution is a waste of energy that can be better spent in other efforts, and I was never looking for that.
Is it usually standard procedure for a hospital to do an autopsy on a deceased pt without contacting the family first?
I'm not really sure, but according to the chaplain that we spoke with, since he was pronounced in the ED, it became a case for the medical examiner, and an autopsy would be performed. This was news to me, too.
I'm not really sure, but according to the chaplain that we spoke with, since he was pronounced in the ED, it became a case for the medical examiner, and an autopsy would be performed. This was news to me, too.
That is understandable, but even so I would still think they'd get the family notified in the midst of doing so! Especially given his condition (contracted with PEG and decubs) and coming from SNF. It seems odd that their P+P is to just whisk the body away without getting in any kind of contact with the NOK.
I am so sorry for your loss and the manner in which it was handled.
I certainly hope you and your family pursue this; it sounds like this facility needs to examine how they do things. Contacting family should have been done early on in the process.
I am really glad you met w/the DON and that they will be putting proper protocols in effect in order to avoid such an experience for future residents in that facility. It is wonderful when we can take a less than optimal situation and use it to benefit those who will follow, as in this instance. God bless and best of luck.
CompleteUnknown
352 Posts
Yes, sorry, I must have posted before reading your latest posts. I hope the facility has already put the new procedures in place so this doesn't happen to anyone else.
Your grief and bewilderment comes through very strongly in your writing. I'm so sorry this happened.