Assignment (q)

Read HISTORICAL CASE STUDY #2: Attentiveness and Surveillance and submit APA Paper due by Sunday at 2359, write a paper addressing the following:

a.      Describe what factors surrounding attentiveness and surveillance contributed to the outcome of this case study.

b.      What did you learn from the Case Study?

Paper must be at least 1 page, excluding title page and reference page. (at least 1 reference no more than 5 years old), make sure to reference the article.

HISTORICAL CASE STUDY #2: Attentiveness and Surveillance

THE IMPORTANCE xOF CROSS-MONITORING TEAM MEMBERS’ PERFORMANCES

HISTORY

This case involved three shifts of nurses over a 24-hour period working in a long-term care (LTC) facility. The facility included three separate units with 40 beds per unit. A licensed practical nurse charge nurse was assigned to each unit. One registered nurse supervisor was responsible per shift for the oversight of all three units.

Ms. Kathy Chin had been admitted to the LTC facility in October with heart failure, bipolar disorder with depression, constipation, history of gastrointestinal bleed, glaucoma, and discomfort. She required total care and was not able to effectively express her needs to the LTC staff. In January she had a bowel impaction, and Fleet enemas were administered. She was discovered unresponsive in her room the next afternoon and was transported to the hospital. Blood work revealed that she had a urinary tract infection. She was administered antibiotics and discharged back to the LTC facility.

Six weeks later, Ms. Chin had another episode of constipation. The day shift Nurse Supervisor, Ms. Angela Guilarte, notified Ms. Chin’s physician, Dr. Brian Fisher. Dr. Fisher ordered an x-ray of Ms. Chin’s abdomen, and it revealed severe constipation with fecal impaction. Dr. Fisher ordered clear liquids only and “Fleet enemas until clear.” This was the same regime that was previously ordered and administered to Ms. Chin in January.

A licensed practical nurse, Ms. Margaret Reyes, took the order by telephone, notified day shift Nurse Supervisor Guilarte, documented the order in Ms. Chin’s chart, as originally received from Dr. Fisher, and on the medication administration record [MAR] “enemas continuously until clear.” Practical Nurse Reyes, who received the order for “Fleet enemas until clear,” questioned the order and discussed it with Nurse Supervisor Guilarte. They determined that the enemas should be administered every 3 hours until the return was clear but did not clarify this with Dr. Fisher or pass this information on to the next shift.

The enemas were administered over a 12-hour period by three licensed practical nurses working various shifts. Again Ms. Chin was found unresponsive, and she was transferred to the hospital where she died 6 hours after admission.

THE NURSE’S STORY

I came to work early that evening and was told that the licensed practical charge nurse for one of the units had called in sick. I realized that I would have to cover the patients for the licensed practical nurse as well as provide supervision for the other two units. I received a short verbal report from Ms. Zellner, the evening shift registered nurse supervisor, who reported Ms. Chin’s bowel impaction and the order to administer Fleet enemas until clear. I was told that Ms. Chin had been given three enemas prior to my shift.

It didn’t occur to me that I should assess Ms. Chin and review her orders. I started administering the medications on the unit I was covering for the absent licensed practical nurse. About 3:00 AM, Ms. Mary Pellagros, a licensed practical nurse assigned to Ms. Chin, came to me and said she did not feel comfortable with the order for Fleet enemas until clear. Ms. Chin’s blood pressure was 70/56, and eight enemas had been administered. She asked if the order should be changed. I told her to call Dr. Fisher. I also told Practical Nurse Pellagros to ask if we should start an IV for fluid replacement and draw stat labs to check her electrolytes. I did not assess Ms. Chin as I trusted Ms. Salamino to follow through.

Practical Nurse Pellagros later told me that Dr. Fisher repeated his order for “Fleet enemas until clear” and “reluctantly gave an order for an IV.” Dr. Fisher refused to order stat labs. I didn’t ask Practical Nurse Pellagros if she had informed Dr. Fisher of the number of enemas that had been administered (eight). It took several hours for the IV fluid and pump to be delivered to the facility. I went to Ms. Chin’s room and started the IV. I did not conduct an assessment, but Ms. Chin was responsive. At the end of the shift, I reported off to the Shift Supervisor Guilarte and told her about the new orders that were obtained during the night. I did not report the number of enemas given on the night shift (eight plus four), and I did not check to see if vital signs had been documented during the night shift.

It is my understanding that the day shift administered three more enemas to Ms. Chin after which, at 1:00 PM, she was found to be unresponsive. She was then transferred to the hospital. I trusted Practical Nurse Pellagros to provide the care Ms. Chin required. Nurse Pellagros called Dr. Fisher and carried out his orders. I didn’t believe it was my responsibility to challenge a physician’s order, and I didn’t believe I should call my supervisor, the Director of Nursing, in the middle of the night.

INTERVIEWS WITH WITNESSES

All staff members who participated in or were present during the period of time the enemas were given were fully aware of Ms. Chin’s history and the outcome she experienced with the first bowel impaction she had in January. None of the staff members were aware of the number of enemas that were administered during the second episode over the 12-hour time frame, after the order was received from the physician.

Dr. Fisher stated that Practical Nurse Pellagros called him during the night and questioned the order for enemas until clear but did not tell him how many enemas had actually been administered. He refused to clarify the order and believed the order was appropriate as he had given it. He said Practical Nurse Pellagros should have used her “common sense and not administered that many.” We recommend the use of the SBAR communication approach, which provides the standard framework for conveying key information. (The acronym stands for Situation—a brief statement of the problem; Background relevant for the situation at hand; Assessment—summary of what the clinician believes is the underlying cause and its severity; and Recommendation—what is needed to resolve the situation [

Pope, Rodzen, & Gross, 2008

].)

CASE ANALYSIS

This case demonstrates the fatal outcome that emerged when nurses did not recognize the importance of continuous attentiveness and surveillance when providing what is perceived to be routine care. Bowel care in a long-term care facility is a part of most residents’ care plans and is competently provided by licensed practical nurses, and sometimes by unlicensed assistive personnel.

The registered nurse supervisor did not recognize her responsibility to intervene when the licensed practical nurse came to her with questions about the physician’s order and reported that the patient’s blood pressure was low. The registered nurse did not fully assess the situation or the patient. She provided the licensed practical nurse with some suggestions, such as requesting an order from the physician for IV fluid replacement and a stat blood draw. She was aware that the patient’s condition was declining but allowed the licensed practical nurse to continue to carry out an order that would endanger the patient. By not assessing the patient herself, she did not provide the input necessary to give the physician a clear picture of the patient’s declining physical status and did not intervene when the physician continued to refuse to discuss further options for her care. The registered nurse did not contact her supervisor to obtain direction when she knew the physician’s order was not appropriate. She did not check back with the licensed practical nurse and reassess the patient.

There were systems breakdowns as well as individual practice breakdowns that led to the patient’s death. The LTC facility did not have a system in place to address short staffing when a licensed practical charge nurse was unavailable for work. This meant that the evening supervisor had to fill in for the absent licensed practical nurse and sacrificed the attention needed for supervisory functions during the shift. The environment provided by facility management did not encourage the registered nurse supervisor to contact the director of nursing with concerns regarding emerging issues during the night shift. The registered nurse supervisor did not understand her responsibility to assess the resident and provide adequate surveillance to ensure that the licensed practical nurse who was providing the direct care was meeting the patient’s needs. The registered nurse did not initiate follow-up with the licensed practical nurse to ensure that the patient’s status did not continue to decline. The registered nurse should have contacted the physician and challenged the order for “Fleet enemas until clear.”

In this case, lack of attentiveness and surveillance and faulty intervention on the part of the registered nurse supervisor prevented the patient from receiving the interventions required for her declining physical condition. The registered nurse supervisor contributed to the patient’s death with the inappropriate administration of the physician’s faulty order. This cascade of errors could have been prevented if the registered nurse supervisor, who was aware of the patient’s history, had identified her responsibility to provide attentive surveillance of this emerging and preventable situation.

SUMMARY

Monitoring and thoughtfully observing and responding to changes in a patient’s clinical condition or concerns is a bedrock nursing function and skill. Attentiveness without engagement with the patient falls short as these extreme cases illustrate. Sleepiness, fatigue, and disengagement are all personal factors that influence the attentiveness required for effective monitoring and surveillance of patients. Poor staffing, a culture of low expectations, and an inadequate staff mix of professional nurses and unlicensed assistants are institutional factors that disrupt attentiveness. Patients who are somnolent, cognitively impaired, or have a decreased level of consciousness are at great risk when nursing surveillance and monitoring are below standard. Patients who cannot effectively call for help or articulate their needs depend on the attentiveness of nurses to protect them from the many threats to their safety while they are hospitalized.