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]

There is multiple documentation entries from myself and the supervisor (after finding the problem) of trying to contact the family prior to sending the patient out to try to see what their wishes were since the patient was a DNR.. But it should've been done over the weekend.. Sigh. I was at home enjoying my days off for that weekend,they can't touch me there.

[BuckyBadgerRN, ASN, RN]

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.

Except HIPAA DOES see it as a problem. TOTALLY not allowed

[Mn nurse 22]

Even an ER nurse is not allowed to look up a patient they admit to see if they are doing OK or if they did the right interventions

[TigerxLiLy]

Patient is baaaaack! :). Good outcome.. For the most part... Just much weaker of course... But overall back to the same person.

[kgoode0919]

Holy hell! That poor patient. You did a wonderful job!

[la_chica_suerte85, BSN, RN]

ABG after 12hrs sending over to hosp= pH 7.5, pCO2 32.2, pO2 116..

I have not read a ABG since school (been a nurse since 2008 but have worked in LTC since) Just know that is alkalosis... MD note states now in Resp alkalosis, however did have metabolic alkalosis due to high PCO2.. does that sound right?

K+ critical low today, but every other lab that WAS critical is stabilizing. Good news. GFR is 17, BUN 96, Cr 2.8... crazy

Maybe she was losing H+ ions through her GI tract (hence the suspected dumping syndrome) and not voiding out the excess HCO3. I don't know why high CO2 would point to metabolic alkalosis, though. The critical low potassium, however, does since it contributes to a greater shift in H+ ions into the cells. The low Chloride also contributed to this in a similar manner.

[lumbarpain, ADN, RN]

Are you sure you don't work in my facilty? I get so frustrated with things like this.....but you were very aware and alert to the fact that this patient was going down.....don't know whats wrong with some nurses working today..it scares the crap out of me.

[TigerxLiLy]

it is frustrating- Especially when I just relay to the supervisor of things that she needs to know when I review charts for my med a patients and go over therapy minutes with the DOR ---exhibit A: "Heard mr.blank took a fall last night and hit his head,but the Neuro check UDAs are not being done.. That there is only one Neuro check uda from his initial fall and no f/u. I just wanted to let you know so you can figure out what's happening and get the Neuro checks back to being done. Therapy said patient was more lethargic today and just called to inform me that they could not get all their treatment minutes in...I'm aware patient gets this way after diaylsis, but with fall it is just something to watch. I wanted you to know that I saw we didn't have the neuro checks done like we are suppose to and knew it was something you needed to be aware of. Just in case the lethargy is not dialysis related."

Well supervisors took this as if I was demanding something be done now (yes,same supervisor as previous) and had a big ol hissy fit in my office. "Well did you look at the patient yourself instead of just listening to therapy, mr.blank is always lethargic after dialysis. I just saw the patient in the dining room eating and they looked fine"

Had to stop her rant and just tell her " Yes, I am aware that that does happen after dialysis. BUT the patient did fall and hit their head and I did not want nursing just assuming it was due to dialysis especially since there is no Neuro checks to prove anything. That I am just informing YOU the supervisor that a patient under YOUR care has these issues so YOU can deal with them how ever YOU see fit."

[ComeTogether, LPN]

I have a thought I want to share.

It was mentioned that the CNAs, among other staff had been saying the patient didn't look right.

Just wondering if the nurses in that facility really listen to their CNAs. I know that as much as I hear that we're the "eyes and ears", it is really hard to be taken seriously, especially if the nurse isn't permanent and doesn't know me.

Just food for thought. Some of us really know when our patients aren't right.

[TigerxLiLy]

your completely right. we have some really good cnas too. I really don't know what happened over that weekend sadly. Just glad the patient outcome was good and we can figure out what the family/patient wants if it happens again.. we are getting weekly bmps now. So we should not miss this again

[jadelpn, LPN, EMT-B]

Just to throw a thought out there. It burns my butt that lab came, lab drew, labs done, and then they just sort of cancelled the order, were going to "wait" until the next time they came out, because the labs were "incompatible" with life?!?!?!?!

You are kidding me.

There needs to be a huge process change, (and not just a talking to between supervisors).

All criticals need to be reported promptly, regardless of what the lab tech feels. They needs to get their butts back for a re-draw STAT or a decision then needs to be made to send and treat, or comfort care.

When someone's kidneys are non-functional, it is not comfortable. And why was this patient made to suffer for a few days whilst CNA's were high-fiving they didn't have to do peri care?!?!?! (

And as part of Part A, I believe that a nurse needs to assess daily. That means head to toe. That means to check depends for urine. If none is present, speak to the CNA to advise nurse when peri care is due (and I am assuming that turns, repos, and peri care is done Q2 hours, no?) And the NURSE needs to assess this, needs to document this, needs to be on top of this. Not to mention that is there documentation that a fluid bolus is given as an order states?

As a licensed person, it is imperative that assessments are done. And done more frequently and MD notified when there is a major change in condition. I could speak to the fact in skilled/LTC there's one nurse to 50+ residents, however, there needs to be a team member who is specific to assessments if the nurse can not get to them all. So staffing should be also looked at closely. And the bit about the head strike. This is insane! The resident falls and strikes head. There's change in condition. No neuro checks are done with any bit of consistency. There is no follow up testing (head CT?!?!?). How can anyone justify any of this?

There needs to be some significant changes in this facility. Even a nurse educator to direct how this will not happen in the future. A nurse who does treatments to do assessments.

Medicare has some strict guidelines to say the least. How can one bill for treatments that were not done, or not done correctly? How does one justify this?

And yes, if a person is accessing medical records for patients no longer in their care, it IS a HIPAA violation. You have no need to know as your position as MDS coordinator and resident is in acute care. And it does leave a footprint.

All in all, there needs to be some staff additions, new policies, better outcomes--and risk management needs to be involved in this, compliance needs to be involved in this, and as a Part A facility, there needs to be some consistency and truth in what is being documented and what is actually being done.

[psu_213, BSN, RN]

All criticals need to be reported promptly, regardless of what the lab tech feels.

This happened to us in the ER. A gentleman came in as a cardiac arrest. Got pulses back. Color was really bad. Where labs were drawn, the sample was quite dilute appearing--there was nothing that could have contaminated the draw--his blood looked like this from his A line, his QLC, his peripheral IV, etc. Blood was sent down. Uncrossed blood was ordered and a couple units given. CBC still not back. I called to the lab. Their response: "it was incompatible with life and obviously diluted, so we didn't post it." Me: "It was a good draw and this man is quite anemic appearing…what was the H&H?" Lab tech: "Well, where did you get the sample?" Me: "I really don't have time to go over this, what was it." Turns out the Hgb was 1.8. Yes, incompatible with life, but this was the true value for this man. He was already getting the uncrossed blood, but it was quite annoying that the lab tech(s) decided to exercise his/their judgement…and then not tell anyone about it (his platelets were also quite low). Come to think of it, in retrospect, I should have written up an incident report on it.