Lessons on why not to "Assume" things.

[TigerxLiLy]

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!?

[TigerxLiLy]

Have full rights. No issue. Our facility contracts with the hospital in question. We get most of our admits from it. We use the progress notes,therapy notes,labs,dc summaries, h&ps, consults, etc for continuty of care in our facility. Alot of times the D/c orders are usually missing cardio/sx f/u orders, but by having the access we can get the answer easily without having to call offices and wait.I like learning from reading how they take care of residents.

I dont see how I have broke HIPPA ... As this is our LTC patient that we are just following. I havnt told you guys any other identifying information, to my knowledge..

[heron, ASN, RN]

Have full rights. No issue. Our facility contracts with the hospital in question. We get most of our admits from it. We use the progress notes,therapy notes,labs,dc summaries, h&ps, consults, etc for continuty of care in our facility. Alot of times the D/c orders are usually missing cardio/sx f/u orders, but by having the access we can get the answer easily without having to call offices and wait.I like learning from reading how they take care of residents.

I dont see how I have broke HIPPA ... As this is our LTC patient that we are just following. I havnt told you guys any other identifying information, to my knowledge..

A good question for your legal department. If the resident is still in the hospital, then you are not directly involved in her care and will not be until she returns to your facility ... if she returns.

Our DON can't get info on residents hospitalized from our facility due to HIPAA. The fact that your facility has computer access to hospital records might indicate that it's ok where you are, though.

I agree that it's good to have as much info as possible about a resident's hospital course, but I echo the advice to tread carefully ... maybe ask your risk management or legal person their opinion.

[psu_213, BSN, RN]

The fact that your facility has computer access to hospital records might indicate that it's ok where you are, though.

Just because someone has access to a system does not mean that that person has the right to view all the information on it. I have access to my hospital's computer charting system, I can search the entire hospital. However, I can't look up information on a patient of mine admitted to the ICU even though they used to be my patient.

[FranEMTnurse, CNA, LPN, EMT-I]

Good job Allelez. Sounds like you are a conscientious nurse. Now for a personal experience that did not have a wonderful result, but thankfully, I had a good doc who caught the mistake. I was in the Progressive Care unit in my local hospital with problems of passing out if I raised my head. I had vomited two and a half liters of systemic blood as a result of atrial tachycardia a week earlier. I believe nobody checked my chart prior to doing the rounds, because nobody said or questioned why I was unable to sit up without passing out. I gave numerous verbal clues, telling the caregivers I wasn't able to sit up. The aides took my BP and assumed it should be low without question.

After about a week of this activity, my Physician invited my Pulmonologist in my room to test me for orthostatic hypotension, by placing the head of my bed in the high fowlers position. I immediately told him I was passing out. He diagnosed pulmonary hypertension, and I was moved from the Acute Care Unit to Progressive Care.

The following morning a cute little aide who looked like she was from the Philippines, placed me in the high fowlers position like she did her other patients. I told her I was going to pass out, and she hurriedly lowered the head of my bed and began to cry. Later that same day, the charge nurse entered my room and told me she didn't know what was wrong with me, but she would help me with my personal care. MISCOMMUNICATION between units was the culprit.

The following morning, the nurse emptied black urine from my catheter bag. I was in acute kidney failure. Thankfully, my doctor knew what was going on, and ordered IV Lasix. It restarted my kidney function a few hours later.

[ktwlpn, LPN]

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.

Well,if she gets her "miracle" and returns to the LTC I hope someone speaks to the family about comfort care.It's time to have that talk.

[BuckyBadgerRN, ASN, RN]

I'm interested to know if anyone is looking into how this pt went SO long with NOONE noticing how much trouble she was in! Some big azz balls were dropped with this poor lady. I shudder to think of how much longer she would have hung on if OP didn't come on duty

[heron, ASN, RN]

That's right, BuckyBadger. And that's why the OP should at least consider hiring a lawyer, especially if her only malpractice coverage is through her employer.

If those questions get asked, the ptb will be insisting it wasn't their fault and trying to pin it on nurse error.

It can get really political.

I see more mandatory inservices in the OPs future.

[agcaruso]

I don't see the problem on looking up a patient of yours that is transfered to another unit (as in the previous posters example). We can't learn without feedback about how our actions effect the patient. As long as you don't know the patient personally before they were your patient and you aren't using the informaiton you are gathering to harm them, I think following up should be encouraged.

[danceyrun]

I don't see the problem on looking up a patient of yours that is transfered to another unit (as in the previous posters example). We can't learn without feedback about how our actions effect the patient. As long as you don't know the patient personally before they were your patient and you aren't using the informaiton you are gathering to harm them, I think following up should be encouraged.

Unfortunately I do not think HIPAA works that way.

[psu_213, BSN, RN]

Unfortunately I do not think HIPAA works that way.

It doesn't. There are specific channels through which to go to educate yourself on a former patient (such as through you unit educator).

You cannot take it upon yourself to go through a transferred patient's chart in the name of education. No matter how noble it may seem, it is not allowed.

[icuRNmaggie, BSN, RN]

If the "Supervisor" can discredit the OP, or blame the OP for her negligence and total incompetence, she will.

It is appalling how some people will lie to save their jobs.

I would make a call to my malpractice carrier about a potential claim. Find another position as soon as possible.

[TigerxLiLy]

nah, I'm not running. I'm a MDS coordinator.. This patient wasn't fully under my complete charge (all the patient's in the facility are "mine" per se..but I did not have direct charge over this patient) I only took the iniative to take over when I asked the supervisor,the patient's nurse,and then the DON what have we actually done as interventions for this patient when I kept hearing from the cnas and therapy staff that the patient doesn't look well and she could not participate in therapy (to meet the RUG level that her roll was that day)...When no one specifically stated a intervention other then watching her, holding her pain meds and haldol. I made the suggestion to the DON and the supervisor (they were together) that they need to call the MD and family for our documents. When I followed up 1hr later and they still did not, I went into action mode. Reading the MD notes,seeing that he order labs for that day, checking and finding out what happened with the labs,and finally getting people to realize it wasn't just something to "wait" on...I made a seperate entry in a notebook I keep for myself of what happened ...don't worry. Got about 15 entries in there over the past 2yrs....for my records and took keep up with what happened "off the record"