sleep apnea alarm disabled "pt died"

[got2luvnights]

i am taking a class where we need to analyze a legal malpractice case. i was just wondering what everyone think of this. sorry for the length but i feel that there is a lot to be learned for this case. thank you for your replies.

the patient was a fourteen year old male with multiple medical conditions. specifically, the patient was a quadriplegic, nonverbal and nonambulatory. he had a history of seizure disorder and at the time in question was npo. feedings were given through a gastrostomy tube.

the patient was on an apnea monitor due to an obstructive respiratory condition that required a tracheostomy to be placed.

there were specific orders from the physician that the sleep apnea monitor be turned on "at all times" that the patient was not directly observed.

this would soon present an annoying problem for the nursing staff. under normal conditions, the monitor could "alarm" for no reason, or if the patient held his breath for a moment or two. the patient would frequently use this as a "trick" to get the nurses to come and check on him. at one point, the nurses began to turn the monitor off routinely.

this was soon noticed by the physician and prohibited. he pointed out that the monitor was set to alert the nurses to episodes of tachycardia and bradycardia that the patient was at risk for.

when the nurses continued to turn the monitor off despite the order documentation of the monitor's status was made a requirement of the nursing staff. in other words, each nurse on during a shift would need to document that it was in fact on and in use. this made the nurses individually accountable for the monitor's proper use.

despite these measures, an lpn on duty discovered the patient with his tracheostomy tube displaced and with no pulse or respirations. the patient would be coded, and transported to a nearby emergency department where the pronouncement of death was made.

the nurse stated that the alarms had not sounded and when cardiac leads were removed to begin cpr, there were also "no alarms" heard. other testimony would state that lights on the monitor were flashing, the accuracy of this observation was doubtful.

when the case went to court, curiously, the "monitor" of that day was "missing" from the chart.

the parents of the 14-year-old child would sue the facility for medical malpractice and negligence. the court's verdict found for the plaintiffs and granted a large award.

the defendants appealed.

questions to be answered:

1. were the nurses responsible for the status of the monitor and documenting that it was working properly.

2. were the nurses responsible for the wellbeing of the patient who was a total care patient and unable to care for himself.

3. were the nurses responsible for documenting that the sleep apnea monitor was working properly and having that documentation available in the chart.

the court and jury noted that the nursing staff of the facility had already been reprimanded for "shutting the monitor off" on several occasions. this was with the full knowledge that this action could put the patient at risk of distress.

at the time of the incident, the patient clearly was experiencing respiratory and cardiac distress that would otherwise have been picked up by the monitor and sounded an alarm.

testimony on the equipment itself stated that it was in perfect working order. it was added that even with normal operation, incessant "false" alarms could not be avoided. it was this "alarming" that prompted the nurses to shut the monitor off in the first place. this had prompted the physician's order to keep it on at all times and that the nursing staff "document" that it was turned on and in use.

the responsibility of the nurse to monitor a patient's status and report any changes or distress to a physician is basic to nursing practice. this is mandated in state nurse practice acts and nursing[/url] standards.

the nursing documentation of the monitor's use, mandated by a direct and specific physician order, was "missing" from the day in question. this in addition to nursing testimony that "no alarms were heard" and conflicting testimony about "lights flashing" shed considerable doubt on the credibility of the nurses.

the appeals court affirmed the judgement of the lower court stating that the evidence against the defendants was grossly in favor of negligence.

events in a facility are sometimes beyond the control of the nurse. a patient[/url] can code, or go downhill despite the best intentions and care of the nursing[/url] and medical staff.

in this instance however, deliberate negligence on the part of the nurses resulted in a death that was clearly avoidable. had the monitor been used as intended, it is entirely possible that the patient's condition could have been picked up promptly and a tragedy avoided.

if the facility or family in this case wished to file formal charges with the state board of nursing, it is likely the nurses involved would lose their licenses. it is likely that a formal complaint could involve not only the nurse on shift during the incident, but all the nurses caring for the patient up until that point.

to turn off a potentially life-saving monitor because it "made too much noise" is simply inexcusable. a malpractice insurance policy might offset losses in this case by covering legal expenses and damages to the family. it would not however save the nurses from losing their licenses following a formal board inquiry.

[pricklypear]

I would say classic bad practice!! If you mentioned it, I missed it, but on what grounds did the defendants appeal? I can't believe it even went to court.

[UnewmeB4]

I am curious how they could get the liscences of ANY nurse who cared for him if they had no proof that the nurse had his alarms off.

[pricklypear]

I just don't know enough about legal stuff. But I would think that since the record was missing, there was no proof either way. So, if the nurses were to say the alarms were on, obviously they did not alarm when the patient stopped breathing, so they would have to say the alarm malfunctioned. Would the plaintifs have to prove the alarms were off or would the defendant have to prove the alarms were on ? Or was there just enough circumstantial evidence that there was a history of turning off alarms, a properly functioning monitor, and testimony of no alarms heard?

I read about a case where a pt on a vent in ICU died of hypoxia after her vent alarmed repeatedly warning low O2 flow. The staff couldn't find anything wrong, so they turned the alarm off. They were sued and the hospital lost. I don't know if there was documented proof that the alarm was off or on or what.

[legalnurse22]

Man, I would've loved to have gotten that case. Several problems, just to

mention a few. Deviation from several SOC's, P&P's, documentation, and my

favorite, TAMPERING, if the records were "missing". I bet there were some

people squriming during depositions. But I can't honestly believe that it even

went as far as to go to court, much less the defense trying to appeal it. I've

had cases much less severe, and I had to tell the defense that I think you

might want to settle now because the hospital/staff/MD's don't stand a chance. Remember the plaintiff has the burden of proving all 4 elements in

a suit, unless tampering can be proved, then the burden of proof shifts to the defense. That casts doubt on the whole case. If one thing of importance

can't be produced, then what else is missing or falseified? This was a good case.

Legalnurse22

[ZASHAGALKA, RN]

I turn off Apnea alarms all the time (they are annoying and typically not very reliable);and they aren't considered a SOC if you have a stable patient and a pulse ox active. And I'd never turn a pulse ox off (I know, sats are the last to go).

Apnea alarms aren't reliable because they depend on EKG lead differentials and some patients just don't move their chest enough to create the differential (or have bodies that don't readily comport to the algorhithm). Besides, they are 'trending devices' and not true 'assessment devices'. The real malpractice is not effectively assessing the patient. If a patient is at risk for apnea, why is that not a high priority assessment.

From a liability point of view, I would think that the 'failure to provide' issue is not an off apnea alarm but a failure to stay on top of the potential for apnea in other ways. Apnea alarm is but one small tool in that total assessment -- it's a much greater failure than simply an off alarm.

But I wouldn't turn off an apnea alarm if it was specifically ordered

(and I've never seen it ordered) and certainly not if my patient were at actual risk from apnea. That's an assessment (or in the lawsuit case, a failure to assess).

The caveat here is that I don't know the specifics of the specific case so I am speaking generally and not specifically.

~faith

[mommatrauma, RN]

Excellent case, and certainly an eye opener...think about how many times even in an acute care setting we silence alarms b/c of how annoying they can be...makes you really think...

[VivaLasViejas, ASN, RN]

Thianks to the OP for sharing this. We have a similar problem with our telemetry monitor alarm, which on more than one occasion I have found turned off :angryfire

The monitor used to be in the ICU; now we have one at our nursing station as well so we can respond more quickly to an alarm, rather than have the telemetry nurse call 50 times a shift to tell us somebody's leads are off, or they've got a funky rhythm, or they're in apparent asystole. We've had several incidences where somebody shut it off because the constant beeping---although admittedly annoying---was assumed to be an 'electrical malfunction'. HELLO!!!!! I wonder if they ever stopped to think that the 'malfunction' was in a patient's HEART??!! :angryfire

Management has repeatedly warned the staff NEVER to silence the alarm, yet every now and again I or another nurse will find the volume off, or so low that it's impossible to hear it on a typical busy day. Next staff meeting, I think I'll introduce this case.......might make a few people think. :stone

[Salty1]

If I was counsel for the Defendants I would have only one question: "How much can we settle this for?" This is not the type of case to try in front of a jury - sympathy factor alone might result in a very large verdict. Of course, one may argue that an excessive verdict could be appealed solely on the basis of the amount of money. Defendants insurance carrier might very well ask plaintiff's attorney how much of their policy will he let them save to avoid further legal costs, etc.

[anne_chubbybes]

case in nursing malpractice in philippine setting

[nurse4theplanet, RN]

I turn off Apnea alarms all the time (they are annoying and typically not very reliable);and they aren't considered a SOC if you have a stable patient and a pulse ox active. And I'd never turn a pulse ox off (I know, sats are the last to go).

Apnea alarms aren't reliable because they depend on EKG lead differentials and some patients just don't move their chest enough to create the differential (or have bodies that don't readily comport to the algorhithm). Besides, they are 'trending devices' and not true 'assessment devices'. The real malpractice is not effectively assessing the patient. If a patient is at risk for apnea, why is that not a high priority assessment.

From a liability point of view, I would think that the 'failure to provide' issue is not an off apnea alarm but a failure to stay on top of the potential for apnea in other ways. Apnea alarm is but one small tool in that total assessment -- it's a much greater failure than simply an off alarm.

But I wouldn't turn off an apnea alarm if it was specifically ordered

(and I've never seen it ordered) and certainly not if my patient were at actual risk from apnea. That's an assessment (or in the lawsuit case, a failure to assess).

The caveat here is that I don't know the specifics of the specific case so I am speaking generally and not specifically.

~faith

I agree.

We frequently turn off our apnea alarms for the same reasons. Our monitors display all eight pt rooms in each ICU pod, but if an alarm is sounding...it covers the bottom room number. A false alarm that is constantly going off and covering a certain pt's room is also very dangerous. Our apnea monitors do this frequently because they are so inaccurate. That seems to be more of a problem with the device and method of measurement. No one will die because the apnea monitor is off unless other methods of pt assessment and care are not being done.

Also, our devices monitor BP, HR, and O2 sat independtly...so we can turn the apnea monitor off, but still be alerted to a rise or fall in any of the other parameters.

If I had an order to keep the apnea monitor on at all times, then I would certainly do so.

I don't think every nurse that cared for this pt should lose their license if it can not be proven that they had the monitors turned off.

The only nurse that should be disciplined is the nurse that was taking care of that pt the night he expired. Is this a criminal case or a civil case? I am not all that familiar with legal aspects of nursing. I know that negligence CAN be criminal...which means that the evidence must prove guilt beyond a reasonable doubt. But if this is a civil case, there has to be enough evidence to support what most likely happened. And it sounds like, most likely, this nurse turned off the monitor even if it cannot be proven. Therefore, she could be held accountable in a civil case. However, the board is not a court of law, but a licensing body...and can take the license if it sees fit. The board giveth...and the board taketh away.

[morte, LPN, LVN]

I agree.

If I had an order to keep the apnea monitor on at all times, then I would certainly do so.

I don't think every nurse that cared for this pt should lose their license if it can not be proven that they had the monitors turned off.

The only nurse that should be disciplined is the nurse that was taking care of that pt the night he expired. Is this a criminal case or a civil case? I am not all that familiar with legal aspects of nursing. I know that negligence CAN be criminal...which means that the evidence must prove guilt beyond a reasonable doubt. But if this is a civil case, there has to be enough evidence to support what most likely happened. And it sounds like, most likely, this nurse turned off the monitor even if it cannot be proven. Therefore, she could be held accountable in a civil case. However, the board is not a court of law, but a licensing body...and can take the license if it sees fit. The board giveth...and the board taketh away.

it depends when on the nurse's shift the patient was found....if the nurse just got report and went to check the patient....then it would be the last nurse's prob.....and, playing devils advocate...who was the last person in the room? could the parents have done it themselves?