Ms. Amy Jones was a 55-year-old woman being treated for depression at a mental health facility. She was alert, oriented, ambulating without difficulty, and interacting appropriately with staff. The patient’s family was scheduled for a meeting with her treatment team in the afternoon. During the day Ms. Jones met with her psychiatrist, Dr. Ian Smith, in Ms. Jones’s room. When her roommate came in, Dr. Smith suggested that they complete their session in his office, and Ms. Jones accompanied him to that space. On the way she complained that she felt weak but could make it. During the session she reported that she had a headache, which Dr. Smith attributed to anxiety. He went to look for a nurse to provide medication for Ms. Jones. On his return with Ms. Mary Sullivan, a registered nurse, Ms. Jones was on the floor on her knees vomiting. A physician working across the hall came and assisted Dr. Smith and Nurse Sullivan with Ms. Jones, who was now quite somnolent, into a wheelchair. Dr. Allen, the primary care physician, ordered that Ms. Jones be given Phenergan IM for the vomiting and that the nursing staff monitor her bowel sounds. Dr. Allen reported that she was not informed of Ms. Jones’ complaints of headache or loss of bowel control. Dr. Allen thought that she was dealing with gastrointestinal symptoms, so she had the nurses check for bowel sounds and softness of the patient’s belly. She reports that she received a second callback and was told bowel sounds were normal, the patient’s stomach was soft, and the patient was resting comfortably. Ms. Jones was bathed and returned to her bed. She took the prescribed Phenergan after which she vomited several more times during that shift. She was incontinent of stool once. No one considered conducting neurologic checks because the staff thought Ms. Jones was suffering from a virus. When Ms. Jones’s family members arrived, the nurses advised them that their mother was sick and was sleeping, and would not be able to attend the meeting. The family members could not arouse the patient. The staff said that Ms. Jones had been administered Phenergan for vomiting and would be awake by evening. Family members returned that evening and found the patient still unresponsive with vomit in her mouth. The family checked Ms. Jones’ pupils and found them unequal. The family reported to the registered nurse at the desk, and another nurse checked Ms. Jones’ vital signs and reported them to be normal. The family telephoned Ms. Jones’ primary care physician, Dr. Allen, and the nurse gave him a report. Soon after this call, an ambulance transported Ms. Jones to the hospital for evaluation. Ms. Jones subsequently died at the hospital. Ms. Jones’ daughter stated that the registered nurse did not assess her mother; on arrival in the unit, the EMT assessed Ms. Jones. Ms. Jones’ daughter did not believe that her mother had been adequately monitored from noon to 6:30 PM. She also complained that the nurses were laughing at the family’s concerns about the condition in which they found their mother. Ms. Cherie Hoffman, a registered nurse, had been employed at the facility for 25 years. She began her career as a nursing assistant, a title she held for 7 years. She then served as a licensed practical nurse for 10 years and then as a registered nurse for the past 6 years. She was familiar with all of the policies and procedures of the facility. On the day of the event Ms. Hoffman was working as the charge nurse; she noted that it was a particularly busy day. She returned from lunch and was informed by Nurse Sullivan that Ms. Jones was ill and had vomited. She was bathed, and the staff had documented her vital signs, completed the Glucoscan, and medicated Ms. Jones with Phenergan per Dr. Allen’s order. The family was not notified of a change in Ms. Jones’ condition because they were expected for a family conference at 3 PM, and Nurse Sullivan hoped that Ms. Jones would feel better by then and could participate in the conference. Nurse Hoffman assisted Nurse Sullivan in monitoring Ms. Jones throughout the rest of the shift. Nurse Hoffman had understood that Ms. Jones had not been sleeping well and thought it would be good to let her sleep. Nurse Hoffman thought Nurse Sullivan had last assessed Ms. Jones at 7 PM. Nurse Hoffman states she was never informed that Ms. Jones had collapsed prior to vomiting or that she had a headache, or that Ms. Jones was somnolent after the episode. She reported that Ms. Jones had a history of headaches, nausea, and dizziness, all of which had been attributed to medications. Nurse Sullivan recalls reporting everything to Nurse Hoffman. Nurse Sullivan said she had checked bowel sounds as directed. Ms. Jones was incontinent of stool at 2 PM. and was bathed and repositioned. Around 6 PM. Nurse Sullivan straightened Ms. Jones in bed and said that Ms. Jones looked comfortable. Nurse Sullivan said that she did not feel anxious about the patient, as she thought Ms. Jones was sleeping. Ms. Jones was not on 15-minute checks, but Nurse Sullivan recalled checking on Ms. Jones frequently throughout the shift to assess for vomiting. Dr. Smith stated that, in retrospect, he should have personally talked to Dr. Allen about Ms. Jones’s condition and communicated to Nurse Sullivan that Ms. Jones had complained about a headache prior to the episode. PATIENT MEDICAL RECORD: PROGRESS NOTES (ORIGINAL ENTRY AT 7 PM) O/B client showered and met with Dr. While out with physician, client had episode of vomiting small amounts. Over a period of 30 minutes, client was medicated with Phenergan. Client was later incontinent of a moderate amount of stool. Assisted with activities of daily living (ADLs). Notified Dr. of situation. No further change in Dr.’s orders. Continues to be unresponsive. Physically ill today. Keep MD informed of changes. Registered Nurse Sullivan ADDENDUM TO PROGRESS NOTES, DATED TWO DAYS LATER (MEDICAL RECORD ENTRY) Received a call to assists client in Dr.’s office; client lying on floor, diaphoretic, reported to have felt weak, nauseated, dizzy. Client started to vomit. Assisted and supported client while she vomited 3 times. Two assisted to wheelchair then back to bed—minimal efforts given by patient with transfer. VS, 12:20 97.2 64 16 134/72 (patient lying down). Reported to charge nurse, client changed and washed. Lung sounds assessed, clear all lobes. Phenergan given at 12:20, blood sugar check at 12:30. Rails up, client on right side. 13:00 noticed to have vomited again. Charge nurse notified, vomitus clear yellow with odor. Charge nurse assisted with cleaning patient. Bowel sounds assessed, low gurgling in 4 abdominal quadrants, info given to charge nurse. 14:00 checks. Client noted to be incontinent of stools. Bathed and repositioned. Pulse 60 reg. & even, respirations unlabored, blood sugar done at 16:20. Client repositioned. During checks from 1800-1900 patient’s head had moved, repositioned. Pulse rechecked 56 reg. & even, all clothing washed and hung to dry. A medical change with nausea and tiredness. Charge nurse and MD notified of all information. Registered Nurse Sullivan NURSING NOTES (ADDENDUM TO ORIGINAL ENTRY THREE DAYS LATER) (MEDICAL RECORD ENTRY) I returned from lunch. Another nurse on staff reported to me that Ms. Jones had an episode of vomiting and had to be assisted to bed, to be medicated. After about 15 min, I went into patient’s room. She appeared to be sleeping. I called Dr.’s office and gave the information to some person. Later Dr. returned call and I explained that the patient had vomited several times. I also told Dr. that the patient appeared unresponsive but also informed her that she had been medicated. I gave her a complete set of vital signs and blood sugar. Dr. expressed concern re a possible abdominal problem and asked me to be sure I checked for bowel sounds. I called Dr. a second time to report the situation and told her that bowel sounds were present and that the patient had defecated. Stool was soft, formed, no further vomiting, and the patient continued to be unresponsive; breathing appeared normal (later call received from Dr.’s office regarding condition). I repeated the previous information. Patient was checked q 15 min all day with staff checking and carefully paying attention to be sure that the patient had not vomited any further. She was turned and appeared comfortable. When the patient’s daughter came in to visit, I informed her of her mother’s vomiting and explained that she had been medicated and was sleeping at that time approx 1500. Family returned at approx 1900 and became quite upset and insisted a Dr. be called. The physician on call at that time ordered the patient to be transferred to ER for medical evaluation. This was done at 1930. Registered Nurse Hoffman FACILITY ACTION Nurse Hoffman was placed on 3-month performance probation. This probation was extended for further observation of assessment skills. Subsequently it was determined that competency in this area was still a problem, and her employment was terminated. Nurse Sullivan was allowed to resign in lieu of termination (termination would have been a result of ongoing performance problems related to nursing assessment and documentation). NURSING BOARD/COMMISSION ACTION Registered Nurse Hoffman and Registered Nurse Sullivan voluntarily allowed permanent revocation of their registered nurse licenses without admission of violation and without admission to any alleged facts.
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