Failure to Provide Nursing Supervision and Timely Notification During Resident Medical Emergency
Penalty
Summary
A licensed nurse failed to provide appropriate nursing services to a resident experiencing uncontrolled pain and performing a risky self-care procedure. The nurse administered acetaminophen and Zofran for the resident's complaints of abdominal pain, nausea, and constipation, but did not obtain a physician's order for Milk of Magnesia, which was reportedly given. The resident, dissatisfied with the interventions, began to perform fecal disimpaction on herself. The nurse left the resident unattended during this procedure to take a meal break, without arranging for another licensed nurse to supervise or monitor the resident during her absence. During the nurse's break, a certified nursing assistant observed the resident with blood on her hands and fingers and informed the nurse, who did not immediately intervene. The resident subsequently called 911 herself to obtain emergency medical services and was transferred to a general acute care hospital. The nurse did not notify the resident's physician or family of the transfer, nor did she communicate the need for family notification to the oncoming nurse at shift change. The resident's medical history included acute post hemorrhagic anemia, ulcerative proctitis with rectal bleeding, and gastrointestinal hemorrhage, placing her at high risk for complications. Upon arrival at the hospital, the resident was found to have emphysematous cystitis, an obstructing ureteral stone, and sepsis requiring emergency intervention. Facility policy required nurses to assess changes in condition, notify physicians and family, and document interventions, which were not followed in this case.