Allegation:
Plaintiff alleged the defendant facility failed to properly monitor, identify, and respond to critical labs and deteriorating condition.
Case Details
The resident, an 84 YOF (5’5”, 145 lb), had a history of osteoarthritis, HTN, macular degeneration, high cholesterol, incontinence, anxiety, and depression. She had two prior admissions for generalized weakness and gait abnormality, each followed by several weeks of inpatient rehabilitation. She took Norvasc, hydrocodone, Duragesic, milk of magnesia, Tylenol, Celexa, Flomax, simvastatin, Xanax, and metoprolol.
The resident was admitted to the hospital by her primary care provider with diagnoses of severe gait dysfunction, degenerative joint disease, osteoarthritis, hypertension, and debility. She remained at the hospital and affiliated rehabilitation facility for two weeks before being transferred to the insured facility to continue rehab. Prior to transfer, her labs included WBC 10.4, RDW 14.7 (11.5-14.5), GRAN % 72.4 (30-70), LYM % 15.6 (25-50), and MONO # 1.0 (1-12).
At the time of admission to the insured facility, the resident was alert, afebrile, continent of bowel and bladder with some accidents, and needed one assist for transfers. Her BP was 128/76, P 76, R 18, and O2 sat 97%. Her PCP ordered fentanyl, alprazolam, Celebrex, and Norco. Two weeks after admission, she was ambulating 150 feet but required assistance when getting dressed.
Over the next month, the resident continued to make improvements. She took daily pain medications, and Xanax PRN. Her PCP noted good rehab potential, improved cognitive and medical status, improved balance and transfer independence, and a good prognosis. Her labs included WBC 8.6 (4.5-11.0), RBC 2.99 (4.0-5.2), HGB 8.8 (12-16), HCT 26.5 (36-46), RDW 15.1, PLT 483 (150-400), MPV 6.5 (7.4-10.4), lymph % 22.6, mono # 1.0, potassium 3.1 (3.5-5.2), CO2 34 (20-30), calcium 7.6 (8.6-10.3), total protein 4.5 (6.0-7.9), and albumin 2.8 (3.3-5.4). Potassium, iron, ferritin, folic acid, B12, and ProSource were ordered.
The next day, labs included WBC 9.7, RBC 3.05, HGB 9.0, HCT 26.9, RDW 15.0, PLT 486, lymph % 18.0, mono # 1.0, and iron 16 (50-135). Ferrousal was ordered. Two days later, the resident received magnesium hydroxide for bowel management. Three days after that, her PCP ordered potassium chloride and ferrous sulfate. The following day, the resident was awake and alert with clear lungs, easy respirations, bowel sounds x4, and no complaints. Occupational therapy noted a continued need for moderate supervision with bed mobility, toileting, and functional transfers.
Seven weeks after admission to the insured facility, nursing staff notes about the resident indicated a stable weight and good/fair appetite. The next day, the urinalysis identified a large amount of blood, trace leukocyte esterase, WBC 10-25, RBC 25-50, bacterial-occasional, hyaline casts 5, and negative nitrates. The resident’s PCP ordered a CBC.
At 8:01 a.m. the following morning, a lab tech spoke with a RN regarding critical values from the 6:00 a.m. labs. Bands 30.0 (3.0-7.0/critical), potassium 3.6, sodium 138, chloride 100, CO2 23, Anion gap 19 (6-16), glucose 152 (70-99), BUN 40 (6-22), creatinine 1.80 (0.40-1.10), calcium 7.7, total protein 4.9, albumin 2.6, WBC 12.1, RBC 3.90, HGB 11.2, HCT 34.2, RDW 16.8, PLT 661, GRAN % 90.9, lymph % 4.3, lymph # 0.5, GRAN # 11.0, lymph 3.0, and metamyelocytes 1.0 (0.0). RN does not recall taking the call. At 10:45 a.m. the lab report was faxed to the insured facility.
At 11:27 a.m., a Fleet enema was administered per bowel protocol; 0.25 mg Xanax was given for anxiety. At 12:49 p.m., staff found the resident pale and slightly diaphoretic, with complaints of abdominal discomfort and shortness of breath. The RN chart indicated she had arrived in the resident’s room around 12:45 p.m., and had found her slightly clammy and hyperventilating, with bluish lips, cool hands, ashen color, anxiety, and O2 sats in the 70s. The resident’s lungs were clear, but hard to assess due to breathing pattern. The RN applied oxygen and sats rose to the 80s. The resident’s lips gained color, but she continued to hyperventilate. She received 0.25 mg Xanax for anxiety at 1:26 p.m., and rested quietly without hyperventilation. At 2:32 p.m., she was resting quietly.
At 3:00 p.m. the resident’s PCP was notified of the critical lab results. Orders were placed for Maxipime 1 gm IV every shift x seven days for respiratory signs or symptoms and elevated bands, a CXR, sodium chloride solution 0.9% every shift for hydration, and a follow-up CBC and BMP two days later. Unbeknownst to the PCP, the next pharmacy delivery would not take place until after 8:00 p.m. The resident did not receive any antibiotics.
At 4:47 p.m., the resident was given ibuprofen and Norco. Nursing notes indicate she was alert, nodded her head yes to questions about pain, and had some difficulty swallowing her medication. An hour later, her skin was cool and pale; she would only sip liquids. At 7:30 p.m., the resident was resting with easy respirations on 3L NC, infusing IV, cool and dry skin, and no agitation. At 8:34 p.m., staff found the resident with cold, pale skin, and no blood pressure. No resuscitation attempts were made; there was no DNR/DNI order on file.
The resident’s estate filed suit alleging failure to properly monitor, identify and respond to critical labs and deteriorating condition, failure to timely communicate critical labs to a physician, and failure to diagnose and treat sepsis, resulting in the resident’s death.
Expert Testimony
The estate’s expert witnesses stated the nursing staff failed to promptly notify the resident’s PCP when they learned of critical lab values. The experts were also critical of the staff’s ability to take and record the resident’s vital signs. Finally, the experts stated the resident lost the chance at surviving sepsis due to a failure to timely transfer her to the hospital.
Defense experts could not support the care provided at the insured facility. Staff should have acknowledged the resident’s lab results were significantly different from previous labs, recognized the signs of sepsis, and notified the PCP of the labs in a timely manner.
Resolution
Due to a lack of expert support, and an unrelated state agency investigation of the facility, settlement was the best solution for the defendant.
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