Dehydration plays a key role in death in a nursing home

For older adults, dehydration will be brought on by many aspects, but research shows that the foremost causes of dehydration in nursing homes are inadequate staffing and lack of supervision. In the next case, it was determined that the death of a nursing home resident was brought on by dehydration together with a brand new or existing heart condition that was exacerbated by the dehydration. One day, a nursing home resident was transferred to the hospital’s psychiatric ward on account of “aggressive behavior and possible altered mental status.” She was also lethargic and physically unstable. Emergency department staff, who observed the patient for several hours and performed laboratory work, found her to be stable but affected by a psychotic episode. The next morning she returned to the nursing home. When she returned, the patient was still lethargic and confused. The RN asked the registered nurse (CNP) who was working together with her that day to evaluate the patient’s condition and requested that he be returned to the emergency department. The CNP determined that there was no medical reason to transfer the patient back to the emergency department and really useful that the RN wait one other day. It is essential to notice that the nursing home’s unwritten policy regarding transportation fees prohibits nurses from sending residents to the emergency department. The patient’s lethargy and mental changes endured throughout the evening. She was given lorazepam twice. The next day, the identical RN was assigned to the patient’s care and likewise served as the power manager of the nursing home. The patient was acting aggressively, was receiving Ativan several times, was not eating or drinking anything, had slurred speech, and never opened her eyes that day. The RN checked on the patient around 5:00 p.m. The patient, who was awake and lying on the ground on her right side, told the RN to “leave her alone.” Two nurse assistants (STNAs) noticed that the patient was respiration heavily and thought she should go to the emergency department. The RN repeatedly asked the CNP for permission to transfer the patient to the emergency department, but was denied every time. When the RN contacted the director of nursing facility (DON), the DON deferred the CNP’s decision. About an hour later, the patient’s son arrived on the nursing home for a visit and located his mother lying on the ground and never respiration. Someone called 911, but paramedics were unable to resuscitate her. She was pronounced dead within the hospital. An autopsy was requested, nevertheless it was not carried out. Instead, the health worker relied on a review of the patient’s medical records to find out the reason for death. He determined that the reason for death was an epileptic seizure and the cause was hypertensive heart problems. The son filed a lawsuit alleging wrongful death and violation of the state’s Nursing Home Patient Bill of Rights against the nursing home (and its legal entities) and CNP. The Nursing Home and CNP filed a motion for summary judgment, which essentially found that the deceased patient’s son did not present evidence that he was the reason for the patient’s death. The son argued that he had indeed presented sufficient evidence to support his claim through expert testimony. The son’s health worker expressed the opinion that the reason for death was “a new or pre-existing cardiopulmonary disease.” Moreover, laboratory tests of the deceased showed that she was dehydrated, which also contributed to her death. Despite this opinion, the court agreed to the request of the Social Welfare Home and CNP. The son immediately filed an appeal, arguing that granting the motions for summary judgment was an error. The appellate court fastidiously reviewed applicable Ohio law and located that the son had indeed presented sufficient evidence to determine a problem for the jury to come to a decision that the failure to send the deceased patient to the hospital and the CNP’s advice to “wait and see” , just like the patient, also caused her death. The court’s judgment was overturned and the case returned to the court of first instance. It is obscure why CNP took a “wait and see” approach to this patient’s condition. The patient’s condition clearly indicated that something was flawed and didn’t improve over time.

As a CNP, it is difficult to imagine that her scope of practice wouldn’t allow her to avoid the power’s unwritten policy that a nurse cannot transfer a patient to the emergency department if warranted, no matter transportation charges. Her “loyalty” to the power overrode her legal and ethical obligations to the patient. As a result, her potential liability – and that of the nursing home – is now a matter for a jury to find out.

It appears that the nurse caring for the patient did every part in her power to transfer her to the emergency department. She asked the CNP several times, in addition to the DON. However, questions remain concerning the RN. For example:

1. Her chain of command didn’t end with the CNP and DON. Why didn’t she notify the nursing home administrator or other company administrators of her requests? Why didn’t she contact the patient’s doctor? These details could also be made available on the hearing.
2. Testimony given on the trial stage revealed that the patient refused food and water for 3 days. Had intravenous nursing interventions been initiated, they might have reduced confusion and other changes in her mental status and can have even prevented her death.
3. Patient monitoring was apparently lacking when the RN expressed her concerns to the CNP and DON.
4. Despite the patient’s ongoing distressing behavior, the paramount approach was to manage medication reasonably than further assess her symptoms and undergo psychiatric evaluation.
5. Performing every day activities could indicate not only dehydration, but in addition possible circulatory system disease. Were vital signs monitored frequently?

It is true that the patient was uncooperative, but consistently monitoring and mitigating threats to patient safety are ever-present responsibilities of the nurse. Regardless of the care setting, should you are caring for elderly patients, all the time assess behavioral change as likely on account of dehydration and, if present, intervene immediately. Continue to watch the patient’s condition, including vital signs, urine output, and cognitive function. Notify your doctor or advanced practice nurse for extra interventions. Failure to take appropriate nursing motion to intervene when dehydration occurs may lead to liability for patient negligence (criminal or civil), a possible wrongful death lawsuit (as on this case), and the potential for disciplinary motion for skilled licensure by the state board of nursing.