Communication breakdowns and inadequate note-taking seem to be primarily responsible for the nursing failures that led to a patient’s wrongful death at the Santa Clara Valley Medical Center. The California Department of Public Health recently announced $75,000 in fines for the hospital arising out of this nursing negligence incident.
The respiratory therapist responsible for the patient was not aware of orders to transfer the patient from the hospital’s ER to the transitional care unit (TCU). Typically respiratory therapists are needed to safely transport ventilator patients within a hospital. The first nurse failed to notify the respiratory therapist of the transfer and a second nurse reviewed the patient’s notes after a shift change and incorrectly determined that the patient could be taken off the ventilator for the transfer.
The second nurse took the patient off his ventilator and placed an oxygen mask on the patient. The patient was then scheduled to be transferred to the TCU by a hospital transporter (HT).
The HT arrived and noted that the patient’s head was tilted and that the patient was nonresponsive with his eyes open. The second nurse told the HT that the patient was non-verbal, which was odd because the patient was attempting to talk when he first arrived at the ER.
The HT was also concerned that the patient had an oxygen mask placed over his tracheotomy, which he had never seen before to transport a patient. A third nurse told the HT that the oxygen mask was “okay” and directed the HT to transfer the patient to the TCU. The HT then asked what he should do if the patient experienced difficulties during transport and was told “nothing will happen” by the third nurse, who only made a quick visual inspection of the patient and did not know that the patient was ventilator dependent.
Things only got worse when the HT arrived at the TCU. The HT noticed that the patient was cold to the touch, had his eyes rolled up, and that the patient’s lips were blue. A TCU nurse responded to the patient’s room and immediately began CRP after calling a rapid response alert for cardiac arrest.
The patient was revived and transferred to the ICU, but he died five days later after his family made the decision to discontinue his life support.
CDPH officials found that the patient was improperly removed from a ventilator by one of the ER nurses without a doctor’s order. He was then transported by an HT who was not qualified to transfer the patient without a nurse’s assistance.
State officials found that the patient’s death was a direct result of the nursing staff’s failure to provide an “accurate, ongoing assessment of the patient’s ventilatory status.” The hospital responded to the CDPH findings by revamping its policies regarding patient transfer and has implemented an escalation plan for employees like the HT who believed that the patient shouldn’t be transported.
Source: California Department of Public Health, “CDPH Issues Penalties to 13 Hospitals,” June 1, 2012