Lessons on why not to "Assume" things.

Specialties Geriatric

Published

Specializes in LTC-Geriatric-PPS-MDS.

Got to work at 11AM and read over our facilities "Communications" board. Noted that one of the Part A residents had a medical decline over the weekend according to some of the notes ("Ms.X is noted to be more lethargic", etc)

I went and read some of the nurses notes for over the weekend.. "11/29-Ms.X refused to eat/drink. Scheduled med pass bolus via peg tube and fluid flushes provided. Resident is noted to only respond to tactile simuli at this time, noted increased tremors in extremities due to Parkinsons"

"11/30- resident continues to be lethargic, vitals 130/64,89p, 19r,97%o2 sats, 97.9T, no changes in residents status."

I say to myself "No MD was notified!? maybe she isn't that bad..."-- went down to look at the patient myself..

1. The resident does not have a active Dx of Parkinsons, Her tremors were only noted to be in her BLE when she was sitting up in her w/c most of the time prior to this weekend.

2. Resident is usually very vocal, yelling at staff to empty her colostomy constantly-- if not the colostomy always pain or to tell staff to "go away" after she calls them in.

The patients baseline is vocall. -- just for background.

I called the residents name, no response-- she is supposedly "HOH" yet, hears perfectly fine when you say "How is your pain". So I say "Are you in pain?" No response.. resident is just looking up at ceiling. Touched residents arm and shook her a little. No response. Did the sternal rub, she turned her head- stated "Ow" and looked at me, but then went back to looking up at the ceiling with a vacant look. Did note that she was twitching in her BUE, which I did not think was her normal. Asked the charge nurse what she thought was going on, Charge nurse was clueless "What you mean? She looked like that all weekend." I told the charge nurse, "Yes.. but that is not her baseline...What have you guys been doing differently for her?" "Oh, Well I just got in report they just held her scheduled pain meds due to lethargy Friday, so That should be going away soon." ..me: "have you took her vitals yet?" .....charge nurse: "yeah, They were WNL, nothing to worry about."

Go to the computer to look and see if the MD/NP saw the patient recently. MD saw on 11/26--Orders for RFP 12/1 ( today! yay! ) Our lab draws on Mondays/Thursdays. So I go and check the lab results in the computer..big "CANCELLED" on the RFP. Look for the reason why ( not enough blood? couldn't get the stick? hemolyized? ).. Go and check our lab book to see what the lab sheet said... Technician signed that she got the blood..hmmmm... weird.

Call the Lab, Ask "Why did the RFP on Ms. X get cancelled?" Lab tech response, "Well, It looks like the blood was obtained through a line, or something other then venipuncture, because -- well the results are incompatible with life, so we cancelled this one and scheduled lab to draw on Thursday instead.." *pause* *blink blink* I state, "Well, Ms.X does not have any "Lines" on her, the only other way to get blood, and I'm assuming that your tech got blood, is through a venipuncture .. My patient looks pretty ill over here, Why didn't you call us first to make sure that the patient wasn't in distress or just notify us that we needed to redraw the lab?"

So, I notify my DON of the issue, I notify the supervisor of the issue and the supervisor states she is going to draw stat labs. Attempted to get blood 2x, She would Twitch/jerk even with someone else holding her arm still and dislodge the needle. So the supervisor gets her vitals. 84/56, 113 pulse, 79%- cant remember the rest.. but those were the ones that stuck out to me..

Supervisor calls MD and reports the vitals, current situation, and regretfully tells MD that we were unable to get any blood to run a RFP panel, that Lab drew blood this morning but is reporting that the numbers are wacky and incompatible with life. You can hear the MD cursing on the other line, literally. So of course we send the patient to the ER. They get the blood with their bad selfs :).

BUN= 235 ( baseline for resident is 35), Cr= 8.9 (BL 0.9), Chloride= "

The supervisor then had the nerve to ask me, "What made you look into all this? I looked at the patient at 8am and didn't seen anything wrong with her." ARE You Kidding me!?

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Nice catch, nurse! You really took care of your resident today (or whatever day). This is one of the nice things about having the same patient/resident a few days in a row or at least a familiar patient/resident. You really get to know their baseline and can catch things like this. A great example on how truly knowing a pt's baseline is so vital.

Hope everything turned out okay for said individual.

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Specializes in LTC-Geriatric-PPS-MDS.

I doubt it is... The H&P note looked pretty grim...minus the fact that patient isnt going into respiratory distress just yet (her O2 sats went to 97% with 3L in ER ) and b/p went up to 110/54 after fluids, calcium bicarb infusion...MD literally did state that he cannot believe she is alive with the lab values, that they truley were incompatible with life in his experiences...But, miracles do happen.

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Specializes in Pediatrics, Emergency, Trauma.

Kudos for advocating for that pt!!! :up:

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Specializes in Hospice.

It sounds to me that there was some tacit agreement or decision that didn't make it into the notes, to allow this woman to die quietly.

There's so much wrong with this story, even without really knowing much about the context.

I agree with the OP, questions definitely needed asking - we have a duty to rescue unless the chart documents a resident, POA or MD decision to the contrary.

Big ethical and legal mess.

Good luck, OP - keep your head down and get a lawyer.

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Specializes in LTC-Geriatric-PPS-MDS.

Nothing in the notes said anything about contacting the family or if the family saw her that weekend. Tried contacting the family (only one contact listed) 3x in 25min prior to sending her out. no answer. So no other choice... because I would of asked her if she wanted to send her to the Hospital or keep her comfortable.. Daughter did call 2 1/2 hrs later.. saying "I wouldnt wanted you to of waited to send her out, if the MD said send her out thats what I want."

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Specializes in HH, Peds, Rehab, Clinical.

Why does OP need a lawyer?

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Specializes in Hospice.

Because if the death or harm suffered by her resident turns out to be a failure to rescue, the facility, its staff and the MDs writing the orders are likely to get sued, especially if the family was never notified of the drastic change of condition. They could also complain to the state agency regulating the facility = surprise inspection = management trying to explain the issues spotted by the OP.

On the other hand, if the family and/or resident decided on comfort care and this was not communicated to the nurses taking care of her, a whole other lawsuit based on charges of assault and battery is a possibility.

Not knowing the context, I have no way of knowing what's likely to happen in this specific case. But just from what the OP was able to share, the hairs are up on the back of my neck.

In advocating for her resident as well as she did, the OP painted a target on her back. In other words, feces roll downhill.

In situations like these, lawyers are much better protection than chux.

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Specializes in med-tele/ER.

If that were my family member I would be grateful to the OP.

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Specializes in Geriatrics, Dialysis.

Holy Moly! What horrid labs! I won't jump on get the lawyer bandwagon as I don't see where anything you did is inappropriate, quite the opposite in fact. At least you were aware of the baselines and saw the change in condition. I won't even jump on the blame the weekend staff bandwagon which I am sure will start soon [kind of surprised it hasn't started already]. I work LTC and have 28 residents, when I am floated to a different unit that also has 25-30 residents I don't know any of those residents and to get my job done I need to focus on the task at hand. Chances are pretty good I would assume this residents condition over the weekend was her baseline unless somebody informed me otherwise. I would of course feel awful about not catching a significant change in condition, but I would also not feel guilty about it unless somebody who actually knew the resident and recognized a change in condition told me there was a change. At that point if I did nothing I would feel responsible for not dealing with it appropriately.

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Specializes in LTC-Geriatric-PPS-MDS.

She was a Part A resident- documented on daily. The baseline and change was obvious only after reading the first 2 notes at the top to the previous 4 prior to the weekend commotion...

I would have to say not seeing a change in baseline after having to document on the resident and typing in keywords as "Lethargic" or "only responding to tactile stimuli" would have you as a nurse on alert to see if this was their baseline..no?

Just to top the cake with the proverbial "Icing": The CNAs did a fantastic job of not notifying the nurses that patient hadnt voided in 24+ hours... hince the reason for her labs to be Horrid. DON is not happy...

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Specializes in Hospice.

Lawsuits rarely have anything to do with doing the right thing. If those higher up in the food chain can nail the OP for their carelessness, they're going to do it. Of course, the OP knows more about the character of her managers ... but many years in this business have taught me that if badness can happen, it eventually will.

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