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Sumary: Monitors and Monitored patients present special challenges to practicing nurses. Like a callbell, when alarms on a monitor are activated, they can signal benign or life-threatening events. In this case, a patient's monitors did not alarm as expected. The patient was in distress and would be found without respirations and pulseless by the nurse on duty.
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.
A Percutaneous Endoscopic Gastrostomy (PEG) is one type of tube:
PEG should be considered for pediatric and adult patients who have an intact, functional gastrointestinal tract but are unable to consume sufficient calories to meet metabolic needs. PEG is inappropriate in patients with rapidly progressive and incurable disease, since nasoenteral feedings over a short interval can provide the same result.
The most common indications for PEG are neurologic conditions associated with impaired swallowing and neoplasms of the oropharynx, larynx and esophagus. Other indications include facial trauma and the need for supplemental feedings in patients with miscellaneous catabolic conditions(1-7) "2
The patient was on an apnea monitor due to an obstructive respiratory condition that required a tracheostomy to be placed.
"A tracheotomy is a surgical opening made into the trachea for airway management. A tracheostomy is the surgical creation of a stoma from the trachea to the overlying skin.
Indications for tracheostomy are:
Need for long-term artificial airway
Upper airway obstruction
Upper airway bleeding
Altered level of consciousness, such as increasing lethargy or obtundation, producing inability to protect the lower airway.
Inability to clear lower airway secretions.
Need for continuous mechanical ventilation
Prolonged endoctracheal tube insertion, causing erosion or pain.
Laryngeal or tracheal fracture.
A nursing duty specific to the patient with a tracheostomy is frequent suctioning. Because air inhaled through a tracheostomy bypasses the bodies natural filtering systems, dust and other pollutants are inhaled directly into the lungs. As a defense, large amounts of mucous are generated and must be cleared to maintain a patent airway.
In cases where the mucous is allowed to collect, respiratory distress can quickly develop.
"Suctioning is a component of bronchial hygiene that involves the mechanical aspiration of secretions from the nasopharynx, oropharynx, and trachea. The airway may be in its natural state or artificial (as with a tracheostomy) or surgically altered (as with a laryngectomy). The patient may or may not be receiving mechanical ventilation. The procedure includes patient preparation, the actual suctioning event, and follow-up care and observation of the patient."4
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" documentation 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 standards.
The nursingdocumentation 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 can code, or go downhill despite the best intentions and care of the nursing 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.
September 5, 1999: Sealed "Rape Kit" Reopened By Nurse. Evidence Inadmissible?
Documentation of observations and findings are basic to nursing practice. Our practice is governed by standards of practice and "protocols" to be followed. In this case, a nurse admitting a rape victim collected and placed in a "rape kit" DNA samples, evidence to be submitted for laboratory analysis. The evidence submission protocol would inadvertently be broken by the nurse. The defense for the rapist would argue this breach made the evidence inadmissible.
State v. Southern, 980 P.2d 3 - MT (1999)
August 8, 1999: Pregnant Prison Inmate Complains of Miscarriage,
Corrections Nurse On Duty Ignores Symptoms?
Ferris v. County of Kennebec, 44 5. Supp.2d 62 -ME (1999)
Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care.
August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
July 11, 1999: Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?
Nursing homes are frequently a patient's destination for rehabilitation following surgery. Common conditions fitting this bill include large bone fractures, hip replacements and stroke. Following these acute episodes, the patients are too unstable to go home and not "sick" enough to have their
hospital stays reimbursed by insurance companies. The purpose of admission to a nursing home is to help the patient regain lost function, strength and health. In this case, the patient would remain in the Nursing Home till her death of complications. Lloyd v. County of Du Page, 707 NE.2d 1252 - IL (1999)
June 27, 1999: Elderly Patient Repeatedly Injured In Nursing Home "Accidents."
Negligence, Coincidence or Abuse?
As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes. When a family member is placed in a facility, a certain standard of care is expected. In this case, a resident was injured repeatedly while under their care. When the patient died a few days after being "dropped" the family sued.
Brickey v. Concerned Care of Midwest Ince. 988 S.W. 2d 592 MO (1999)
May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued.
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)
1. 40 RRNL 3 (August 1999)
2. American Society for Gastrointestinal Endoscopy. January 1, 1988. Role of Percutaneous Endoscopic Gastrostomy (PEG). Retrieved September 12, 1999 from the World Wide Web: http://www.sages.org/sg_asgepub1017.html
3. DrugBase The WWW Guide To Medication. No date given. Tracheotomy. Retrieved September 12, 1999 from the World Wide Web: http://www.drugbase.co.za/data/med_info/tracheot.htm
4. AARC and RESPIRATORY CARE Journal. 1999. Suctioning of the Patient in the Home. AARC Clinical Practice Guideline. Retrieved September 12, 1999 from the World Wide Web: http://www.rcjournal.com/online_resources/cpgs/sotpithcpg.html
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