Case Archive
Nursing Home Administration, Geriatrics
Ref. # 849101

An 83 year-old Ohio woman had a history of coronary artery disease, diabetes, congestive heart failure, atrial fibrillation, angina, hypertension, emphysema, a stroke with some right-sided weakness and expressive aphasia, and a pacemaker implant. During the admission she had angina and urinary tract infection. She was transferred to a nursing home with full resuscitation status. The next day she was evaluated for increasing dyspnea. She had chest congestion, a respiratory rate of 24 up from 18 the night before, pulse 90, jugular venous distension, rhonchi and rales, and trace edema. Angina was treated with nitroglycerine. The next day a chest X-ray suggested pneumonia. Insulin was given twice daily with no adjustment due to lack of oral intake. The next morning the patient was crying out "help," had moist and labored respirations at 40 per minute, chest pain, and slight cyanosis. That afternoon at 1430 another physician evaluated her and ordered hospital transfer in the event of no improvement and/or dyspnea, pain and discomfort. At 1610 and 1650 respiration was at 36 and breathing was labored. At 1725 the woman was found with absent pulse and pronounced dead. The nursing home contacted the chaplain, who notified the family--their first notice concerning the woman's condition. A medQuest nursing home administrator and geriatric physician opined the medical and nursing staff was negligent. Despite specific instructions the family was not contacted when the woman's condition worsened. No blood sugars or other lab work was monitored despite the possibility of hypoglycemia. There was a lack of treatment of pneumonia and heart failure. The nursing home staff failed to transfer the woman to the hospital despite a continuing markedly increased respiratory rate. There was a delay of 35 minutes in examining the woman as her condition deteriorated. CPR was not initiated even though it was indicated. The negligence led to a wrongful and untimely death.

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