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When a patient’s condition deteriorates by Patricia Iyer, MSN, RN, LNCC, @avoidmederrors @patiyer #nursefriendly #nurseup

April 17, 2012 in AvoidMedicalErrors.com, AvoidMedicalErrors.com, Bloggers & Blogs

Reprinted here by permission of Pat Iyer

 
Failure to rescue is a big source of patient injury

Failure to rescue is a big source of patient injury

Failure to rescue is a term that describes the outcome when a patient’s condition deteriorates before the changes are recognized and acted upon. Failure to rescue is a nursing-sensitive performance measure on the list of 15 identified by the National Quality Forum in 2004 to be collected by CMS (Centers for Medicare and Medicaid Services). A 2009 study performed by HealthGrades showed that patient safety incidents with the highest incidence rates were failure to rescue. There were 92.7 incidents (per 1,000 population). Starting June 1, 2010, CMS began collecting data about a facility’s failure to rescue rates.

The use of rapid response teams (RRTs) to provide timely rescue efforts in hospitals has gained momentum and popularity, although not all hospitals have them. The concept originated with a critical care nurse from New Zealand who recognized the need to bring resources to the bedside of a patient whose condition deteriorated before more serious events occurred. Without rapid response teams, nurses who recognize ominous changes in the status of their patients are forced to contact the attending physician and wait for a return call. Should an attending physician refuse to deal with or minimize the concerns of the nurse, the nurse has to use the chain of command within a facility – in effect, to go over the head of the attending physician with the assistance of nursing administration, to find a physician who will respond. This is a slow and difficult process.

RRTs have the capability of bypassing the attending physician to turn what can be a 2-3 hour long process into a 5-10 minute arrival to the patient’s bedside. The use of a team within a facility empowers the staff nurse, and provides a safety net for both the nurses and the patients. Implementation of RRTs has reduced cardiac arrests, deaths, the number of unexpected emergency admissions to ICU, and the length of a hospital admission for cardiac arrest survivors. RRTs build teamwork and spread knowledge and skills throughout the hospital. The goals of the team are to provide immediate detection and diagnosis, to treat patients early, and to mitigate harm by turning adverse events into “near misses”. The system is designed to protect the patient from further harm and to allow for recovery from possible medical errors and system deficiencies.

Is the RRT system working? A survey of 56 staff nurses identified the three categories of reasons for why the RRT was activated:

• The patient exhibited signs and symptoms that were either unexpected or significantly different from baseline.
• Despite the absence of objective data, the nurse had a “gut feeling” that “something was wrong.”
• The nurse was convinced that the patient needed immediate evaluation and was unable to get the treating physician to respond as the nurse thought necessary. This is what one nurse said:

“It’s during shift change so everybody’s calling and running and doing this and that, and we called the doctor and he said, ‘Well, she’s got a pulmonologist on the case, call them.’ He gave us nothing. No orders. No meds. No, no nothing. . . At that point we decided we’re not going to wait for anybody else, we’ll just call rapid response and get them down here.”

Consider this comment in comparison to the often slow process of obtaining medical attention when a facility does not have a RRT. In addition to the direct patient safety benefits of such teams, RRTs empowered nurses and gave them a sense of control over the patient situation, identified other processes negatively affecting patient safety, and improved communication and respect between disciplines, thereby raising job satisfaction.

Sources: Shapiro, S, Donaldson, N, and Scott, M. “Rapid response teams: seen through the eyes of the nurse”, AJN, June 2010, 110 (6), 28-34
www.healthgrades.com/media/dms/pdf/patientsafetyinamericanhospitalsstudy2009.pdf

Extracted from Patricia Iyer, Roots of Patient Injury, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition, in press.

For more like this, kindly visit AvoidMedicalErrors.com

Abusive Psychiatric Patient Restrained, Placed In Seclusion For Angering Nursing & Medical Staff? #nursefriendly #nurseup

April 17, 2012 in Case Studies, Clinical Nursing Case Studies, Malpractice Case Studies, Psychiatric Nursing Case Studies

Abusive Psychiatric Patient Restrained, Placed In Seclusion For Angering Nursing & Medical Staff?
Alt v. John Umstead Hospital 479 S.E. 2d 800

Original URL: http://www.nursefriendly.com/nursing/clinical.cases/091999.htm

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Summary: In dealing with violent, abusive or angry psychiatric patients, the safety of the patient and staff are the priority concerns. When restraints or seclusion are deemed necessary, justification for the measures must be documented concisely. In this case, an unruly patient angered the nurse caring for him. When leather restraints were applied and maintained for a prolonged period of time, the patient would object and later sue for damages.

The patient was admitted after taking an overdose of acetaminophen. This admission was not voluntary. As an inpatient, the patient was noncompliant with therapy and uncooperative. He consistently ridiculed both the nurses caring for him and physicians. He was verbally abusive and difficult to care for.

The physician, social workers, nursing and hospital staff attempted to help the patient prepare for discharge. This included arranging employment interviews and searching for a place for him to go after he left the facility. Throughout this the patient refused to cooperate and continued the abusive behavior.

The point was reached that continued treatment and counseling were discontinued by the physician. The order was written for the patient to be discharged and taken home by a family member the next morning.

In his discharge assessment, the physician clearly stated that the patient did not appear to be a “danger to himself or others.” That night, in a particularly disturbing outburst, the patient began screaming at the nurse on duty and began throwing things. No items were thrown at the nurse or other staff.

The nurse clearly upset by the patient “acting out” contacted the physician and obtained an order for physical restraints and seclusion of the patient. This was around six p.m. in the evening.

The patient would be placed in four point leather restraints and kept in seclusion.

“Seclusion refers to the involuntary confinement of a patient alone in a room, from which the patient is physically prevented from leaving, for any period of time. . .

Restraints may be physical or chemical. Chemical restraint involves the use of psychotropic drugs or sedatives or paralytic agents. Physical restraint involves the use of physical or mechanical devices to restrain movement. Physical restraints may be cloth, leather, metal handcuffs or shackles, car seats, or seat belts.”2

The patient would not be seen by the physician who gave the order for a full six hours following restraint placement. This was the same doctor who had been caring for the patient during the present stay. The doctor was in the hospital for the full first six hours that the patient was restrained.

Arguments have been made that excessive use of restraints can be linked to other problematic issues in hospitals, nursing homes and psychiatric facilities.

“The Department of Justice “will document a high use of seclusion and restraint and tie this directly into inadequate staffing, inadequate treatment programming, inadequate delivery of rehabilitative services, and finally, into the overuse of psychopharmacologic interventions,” Geller wrote.”3

At several points following the initial application of restraints, the patient asked that they be removed and that the physician be contacted. The nurse did relay these messages to the physician. The doctor did not change the order or come to see the patient aside from the single visit.

The patient would remain in restraints and seclusion the entire night. This is a patient that aside from outbursts and verbal abuse, had not gotten violent with the staff.

The decision to use restraints carries with it a huge responsibility to the patient and major risks and liability to the nursing staff, hospital and physician.

“Restraint and seclusion are some of the most precarious of interventions in psychiatry and have long been associated with injury and death, added Dr. Lion, a professor of psychiatry at the University of Maryland, Baltimore. But there are no national statistics on the morbidity and mortality associated with these practices.”4

A lawsuit would be brought against the Nursing staff, hospital and physician. The suit alleged the “restraint and seclusion” had been ordered as a “punishment” for the patient’s angry outbursts and ridicule of the nursing/medical staff.

The patient filed a formal complaint under a “tort claims” statute. Initially, his complaint would be dismissed. On appeal judgement would be made against the hospital.

The hospital appealed.

Questions to be answered:

1. Was the use of restraints and placement of the patient in seclusion justified by his actions and behavior?

2. Was the length of the restraint use utilized by the nurse appropriate to reduce the risk of injury to the patient or staff or excessive?

3. Was the physician negligent in his observation and assessment of a patient whom he ordered into four point leather restraints?

Restraint use has been steadily declining in both nursing homes and hospital facilities.

Regulatory oversight and inspections by accrediting agencies of policies and procedures as a condition of continued reimbursement is now commonplace. Death, injury and excessive use have led to increasing scrutiny of their application.

“A Clear Pattern of Abuse Exposed

In October 1998, The Hartford Courant published an investigative five-part series that revealed an alarming number of deaths resulting from the inappropriate use of physical restraints in psychiatric facilities across the United States. A 50-state survey conducted by the newspaper documented at least 142 deaths in the past decade connected to the use of physical restraints or to the practice of seclusion.”5

On examination of the documented behavior of the client by both the nursing and medical staff, little justification for the use of restraints could be found. Under existing nursing, psychiatric and medical standards, their use in this case was clearly inappropriate. The patient though screaming and throwing items about the room was not threatening to hurt himself or others. This was not the first time that the patient had demonstrated this behavior during the current hospital stay.

This would raise the possibility that the nursing staff, angered by the patient’s behavior, sought to “punish” the patient by calling the physician and ordering restraints. The nurse making the phone call was likely familiar with the fact that the patient had been abusive to the physician also.

Knowing the physician’s mindset towards the patient, the nurse could have guessed that an order for restrictive measures would not be difficult to obtain.

In the absence of documentation substantiating the use of restraint and seclusion with “dangerous” behavior on the part of the patient, a violation of applicable standards of care was clearly demonstrated.

There is the possibility that the nurse “thought” violence was likely and was acting to prevent it from occurring. Even if this was the case, neither the use of restraints nor seclusion in this case was justified.

“Patients and staff in mental hospitals have a right to be free from violent assault, but it must be balanced against the right of patients to be free of unnecessary medication and seclusion. Some staff members fear that whatever approach they take, they will be held legally liable, but both harm and legal damages are likely to be lower if they err on the side of preventing violence.” 6

Restraints, when used are to be used only for so long as is necessary to get the patient under control. Continued use past the “emergency” period is illegal, unethical and dangerous. The so called “emergency” in this case was not legitimate by the hospital’s procedures and protocols. The nurse requested the order regardless. It would have been interesting to have the transcript of the call available for comparison with what the nurse documented as the reason for calling the physician.

“The use of involuntary mechanical or human restraints or involuntary seclusion is only justified as an emergency safety measure in response to imminent danger to one’s self or others. These extreme measures can be justified only so long as, and to the extent that, the individual cannot commit to the safety of themselves and others.”7

The physician in this case shared in the negligence for not checking on the status of the patient sooner. Four point Leather restraints alone are classified as a heavily restrictive measure. The perceived need to add seclusion to the order would be appropriate only in the case of a medical emergency. This type of situation commands immediate attention by the physician or member of the medical staff.

With the physician present on the hospital grounds at the time, his six hour delay in assessing the patient himself was inexcusable. Instead he relied on the questionably motivated report/assessment of the nurse to base his treatment.

Even after assessing the patient six hours later, the physician chose to let the patient remain restrained and in seclusion. The court felt it was appropriate that he share responsibility in the negligent claim for his delayed assessment and inaction later.

For the part of the nurse, it would seem that the decision to call for the restraint/seclusion order was motivated more by emotion than by legitimate observations.

When making the decision to determine if restraints are necessary, the safety of the patient and the staff must be considered. The nurse must be fully aware that the recommendation/order for restraints will often be based at least partially on nursing assessments and information given to a physician. Both the nurse and the physician will often share responsibility for untoward events resulting from their use.

Link Sections:

Abuse: Domestic, Physical, Verbal Links, Direct Patient Care
http://www.nursefriendly.com/nursing/directpatientcare/abuse.htm

Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm

Courtroom Directory:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms.online.htm

Direct Patient Care Links :
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Physical and Mechanical Restraints, Direct Patient Care Links :
http://www.nursefriendly.com/nursing/directpatientcare/physical.mechanical.restraints.htm

Psychiatric Nurses:
http://www.nursefriendly.com/nursing/directory/spec/psych.html

Psychiatric Nursing Links:
http://www.nursefriendly.com/nursing/directpatientcare/psychiatric.htm

Violence & Violent Patients:
http://www.nursefriendly.com/nursing/directpatientcare/violence.violent.patients.htm

Related Nursing Malpractice Cases:

August 22, 1999: Psychiatric Nurse, Sued By Hospital After Developing Relationship With Client?
Wright v. Mercy Hosp. Of Janesville – 557 N.W. 2d 846 – WI (1996)
Summary: Doctors and Nurses by nature of their positions deal with patients when they are vulnerable, off-balance and emotionally needy. When the population includes the psychiatric patient, the potential exists for a client to develop “feelings” for the caregiver. In this case, a sexually abused mother of three was admitted for multiple mental disturbances. During the course of the treatment, a relationship developed and led to sexual encounters following discharge. When it came to light, the patient successfully sued. The hospital would attempt to recover damages against the nurse following her testimony in defense of the facility. This is commonly called a Subrogation action.
http://www.nursefriendly.com/nursing/clinical.cases/082299.htm

August 15, 1999: Violent Psychiatric Patient Attacks Nurse,
No Legal Recourse Against Facility or Psychiatrist?
Charleston v. Larson, 696 N.E. 2d 793 – IL 1998
Summary: It would seem absurd, that if a physician admits and facility assigns a nurse to care for a known violent patient, that it has no legal obligation to protect that nurse against violence. In this case, a psychiatric patient sought admission to facility. On admission, he threatened to attack a nurse. When the patient would follow through on his threat, the nurse was denied legal recourse against the psychiatrist who could have taken precautions against the attack.
http://www.nursefriendly.com/nursing/clinical.cases/081599.htm

August 8, 1999: Pregnant Prison Inmate Complains of Miscarriage, Corrections Nurse On Duty Ignores Symptoms?
Ferris v. County of Kennebec, 44 5. Supp.2d 62 –ME (1999)
Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care.
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm

August 1, 1999: Nursing Duty To Patient, “Does Not Guarantee” Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. – 662 So. 2d 1152 (1995).

July 4, 1999: Diabetic Coronary Artery Bypass Patient, Septic & Noncompliant.  Nursing Duty and Responsibility Questioned.
Patient noncompliance can present serious challenges to nurses  and physicians providing care.  If aware of the proper measures to be taken, what happens when the patient does not agree or comply with the course of treatment?  In this case, a patient after having a coronary artery bypass grafting developed a sternal infection. When advised by a nurse to return for treatment, the patient refused.
Kind v. State Ex Rel. Dept. of Health, 728 S.o. 2d 1027 -LA (1999).
http://www.nursefriendly.com/nursing/clinical.cases/070499.htm

June 27, 1999: Elderly Patient Repeatedly Injured In Nursing Home “Accidents.” Negligence, Coincidence or Abuse?
As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes.  When a family member is placed in a facility, a certain standard of care is expected.  In this case, a resident was injured repeatedly while under their care.  When the patient died a few days after being “dropped” the family sued.
Brickey v. Concerned Care of Midwest Ince. 988 S.W. 2d 592 MO (1999)
http://www.nursefriendly.com/nursing/clinical.cases/062799.htm

June 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Official tolerance for verbal abuse and sexual harassment is approaching zero.  It is clear that both are still prevalent in healthcare settings today.  Enforcing and reporting instances of abuse are critical to an end being put to the situation.  In this case, a physician had a “history” of verbal abuse in the facility involved.  It was the documentation of previous events that made formal action and administration of a suspension feasible.
http://www.nursefriendly.com/nursing/clinical.cases/060699.htm
Gordon v. Lewiston Hospital, 714 A.2d 539 – PA (1998)

May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued.
Gerard v. Sacred Heart Medical Center – 937 P. 2d 1104 (1997)


Sources:

1. 37 RRNL 10 (March 1997)

2. American Academy Of Pediatrics. March 1997. The Use of Physical Restraint Interventions for Children and Adolescents in the Acute Care Setting (RE9713). Retrieved September 19, 1999 from the World Wide Web: http://www.aap.org/policy/re9713.html

3. Martz, Micheal. September 15, 1998. Left Behind / Some Patients Have Been Institutionalized For Years. Richmond Times-Dispatch. Retrieved September 19, 1999 from the World Wide Web: http://gatewayva.com/rtd/special/mentalhealth/mhces15.shtml

4. Nidecker, Anna. 1998. Newspaper Series Puts Spotlight on Restraints. Clinical Psychiatry News. Retrieved September 19, 1999 from the World Wide Web: http://pharmacotherapy.medscape.com/IMNG/ClinPsychNews/1998/v26.n12/cpn2612.08.01.html

5. National Alliance for the Mentally Ill (NAMI). February 17, 1999. Seclusion and Restraint. Retrieved September 19, 1999 from the World Wide Web: http://www.nami.org/update/unitedrestraint.html

6. President and Fellows of Harvard College. 1991. Violence and Violent Patients. The Harvard Mental Health Letter. Retrieved August 15, 1999 from the World Wide Web: http://www.mentalhealth.com/mag1/p5h-vio2.html

7. National Alliance for the Mentally Ill (NAMI). February 17, 1999. Use Of Restraints And Seclusion. Retrieved September 19, 1999 from the World Wide Web: http://schizophrenia.nami.org/update/990217.html

 

 

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Created on August 26, 1999

 

Last updated by Andrew Lopez, RN on Wednesday, December 28, 2011

 


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My Mother’s Story by Veronica James

April 17, 2012 in Patient Advocacy, Patient Education, Uncategorized

Reposted by permission of Veronica James, 4/17/12

OFFICIAL NJ HOSPITAL COMPLAINT:  SELECT MEDICAL CORP.

2/11 Originally to:  Mr. Christopher Law, Senate Finance Committee

 4/11  Ms. Apryl Clark,  Special Assistant to the Administrator, CMS,        202-690-6321

 4/11  HSQI, NJ CMS QIO, Beth Pellicore, x.2105                                       732-238-5570                            

  ****CITED for Sub-standard care Oct 2011

 ***NJ DHSS Complaint # NJ00045157:   

***CITED for Violations of Hospital Licensing Regulations, March 2011

 

***CMS Division of Survey Complaint Intake No.: NJ00047580

***CITED for Violations, April 2011

      Ms Barbara Capers-Merrick, CMS NE Consortium of Surveys,      212-646-2462

 ***Joint Commission Complaint Ref. #  91437SSZ-31561AAH  (filed 4/4/2011)

 ***NJ Ofc of the Attny Gen, Consumer Affairs  (investigation 5/11 in progress)

      Susan Sugalski, Investigator, Enforcement Bureau                                  973-424-8138

      Enforcement Bureau Case  # 35-57-11-790

 Vera Eliscu

Select Specialty Hospital,     PAT # 1501466, Chart # 1251 

Division of Select Medical Corp.

96 Parkway

Rochelle Park, NJ     (201) 221-2399

My Mother, Vera Eliscu, was admitted into HUMC on Jan 1, 2009, for cellulitus in her left foot, had a foot ulcer, and to undergo IV antibiotics.  Dr. David Luongo (c- 201-491-2173), her foot doctor who diagnosed the cellulitus, determined when he visited her at home on Dec. 31, 2008, that she caught the cellulitus at The Chateau, where she took aquatherapy as an out-patient during the Fall of 2008 This is the result of poor infection control at The Chateau, who pride themselves on being the “only aquatherapy facility in NJ.”  An MRI at HUMC showed that the bone was unaffected, so after five days in hospital, she continued the 2-week course of antibiotics at The Chateau, and was told to stay off her foot.  For someone who is used to walking every day and doing stairs, despite using a walker, this set her back.  At The Chateau, she contracted pneumonia in the bottom of her left lung, and C-diff.  On Jan 14, after 8 days at The Chateau, she was sent back to HUMC with a temp of 102 and difficulty breathing.

Mom always ate well and never had a problem swallowing.  That day, Jan.14, She was having difficulty coughing up mucous as it was quite deep.  Her EKG was normal.  I helped her with lunch, and she ate without difficulty.  Later I left to get some rest, and an aide fed her 6pm dinner, when she coughed whist eating, to get rid of the mucous.  She aspirated her food and the pneumonia spread to both lungs.  She was sent to ICU, was intubated and put on a ventilator.  In ICU, she was extubated twice, as she was able to breathe on her own for 14 hours, but there was a lot of mucous, and after a week it was determined that she needed a tracheotomy, PICC line, and feeding tube.  She received a Size 7 trach on Jan 21 from EENT Dr. Brian Benson, 201-489-6520.

 

After 10 days in ICU, Mom was transferred to HUMC step-down, where she was rapidly recovering.  Her PICC line was removed, and she was transferred to Specialty Select (LTAC- same building as Chateau) on Jan 28, 2009, for vent-weaning and PT.

 

Mom had never smoked, drank, nor even had coffee.  She ate a good basic diet, was able to eat anything she wanted without any swallowing difficulty whatsoever.  A classical dancer, yoga teacher, and lap-swimmer, Mom always exercised.  She performed as a dancer in public, whilst holding a marketing sales job, until the age of 75.  At 77, she advised a dance book author.  Her only previous hospitalizations were in 02 and 05 each for a hip fracture.  Prior to that she had never been hospitalized except to give birth to me.  She went to the chiropractor every week through Dec. 2008.  She never suffered any form of dementia, nor any hearing loss.  She had no cognition issues, maintained a feisty disposition, and ran her property for over 40 years on her own, with help only from me.  Highly intelligent, Mom’s mind was always lucid, her memory sharp, her speech clear   Her book collection, which includes very high-minded texts on philosophy, mythology and spirituality, to vouch for her high intellect.  Even whilst in the ICU, Mom would listen alertly and attentively to classical music she used for dance, and she often would do her arm dance moves to it in her bed.  Her spirit and mind were clearly intact as well as her ever-present grace of movement.

 

From Jan. 28 at Select, Mom was doing very well vent weaning, as she had never had a previous respiratory problem.  She was able to breathe upwards of 40 hours straight on the trach collar and completely off the vent, whilst maintaining her chipper and upbeat disposition. Highly cognitive and mobile, Mom was receiving physical therapy and was getting out of bed and getting ready to walk again.  We often spent hours together in her room reading from her precious art books and discussing the state of the world, and what was happening at home.  These were lovely visits, despite her being in a hospital.  We looked forward eagerly to Mom coming home.

 

A week after entering Select, on Feb 4, her trach had problems being suctioned, so it was changed to a size 6.  Her tube had air leaks, and on Feb 7, I noticed her voice was slightly raspy.  I was with her until 10pm that evening watching a movie and she was speaking and moving normally as usual, as even with the trach, I could read her lips quite easily.  I had arranged to have Mom’s hair and nails done that week as a gift, since she could not eat her Valentine chocolates.

 

***At midnight (Feb 7 into Feb. 8), after I left, her trach was again changed, without any physician’s order, to a size 4 by RT Julio Bautista, a per diem agency temp.  Size 4 is very small, short and difficult to suction.  I called to check on Mom at 6am on Feb 8, and again at 8am, and all was well.   Two hours later, whilst I was in church, I received a terrible message that Mom had an “event.”  Her inappropriately small Size 4 trach slipped out of her airway and she lost oxygen for several minutes, causing a hypoxic episode with PEA.   Remember it was downsized twice in one week, into a fresh stoma, only two weeks following surgery.

 

***I later found out that this was caused when the RN & CNA turned Mom that morning, and did not pay attention to the smaller size of the trach, so it slipped out during turning.   The nurses then negligently left her side, with Mom receiving no oxygen!!

 

***The staff purposely failed to report this nurse issue to me.  I only found this out in April AFTER Mom was out of Select and AFTER I retrieved her Select medical records, when I had an RN not affiliated with either facility read the records and interpret them for me. Due to this covert action, I spent several months in further agony speculating on how this happened.  Select PURPOSELY covered this up and LIED!  This is Mental Anguish.  I reference no less than eighteen (18) Joint Commission Standards and Sentinel Event Alerts Addressing Conflict and Communication, including RI.01.02.01, EP 20, 21, 22, which requires disclosure of unanticipated outcomes.

 

The respiratory staff immediately got 100% oxygen into Mom, and her heart rate was normal.  She was conscious.  She was then improperly bag-breathed, in which the air went into her face subcutaneously, and when I saw her 90 minutes later, her face was puffed all on one side, and she was unconscious and in a coma.  She had never been unconscious before, and I had never seen her like that! 

 

I stayed by her side, horrified and shocked, as Noella, the charge nurse, examined her.  Mom could see, because her pupils responded to the penlight when Noella lifted Mom’s eyelids to shine the light into her eyes.

 

Mom could definitely feel pain and I was witness to her pain and suffering.  About a day after the trach event, she started to come to more and more, and was quite wide awake and frightened and very upset at not being able to verbally express herself, as she has always been very eloquent in her words and highly intellectual.  Mom winced and grimaced visibly in extreme pain, and looked pleadingly at me for help, and I felt powerless to help her.  I asked her: “Can you hear me?”  She nodded with a grimace.  I asked her “Do you love me?”  Again she nodded with a grimace.  At one horrifying moment, she looked leading at me and was trying to cry out, before she fell back into a deep coma.  She was VISIBLY in pain & suffering and in extreme agony with not being able to speak nor to move, and she NEVER SPOKE AGAIN!  This is unacceptable!

It would have been appropriate to have an EENT change her trach to begin with, rather than after the fact of her sustaining such a devastating injury.  When I refused to consent to send Mom back to HUMC, I requested that an EENT come to Select to take care of it, and was promptly told that Select did not do that, and that no EENT “had clearance” to come there.  This too is negligent, as at Chateau, (and in the same building as Select), an EENT, Dr. Lesserson, has clearance, and comes there once per month to change trach’s in special circumstances that may be too risky to be changed by regular staff (like my Mom’s).  Had Mom’s trach been properly changed by an EENT and not by an RT who acted independently, that horrible medical event would no doubt have been avoided, Mom would then have completed her rehab and vent-weaning (which was going very well), and been home by late Feb./early March – and we would not have had the enormous pressure and difficulty we had been faced with.

 

After waiting two days for an available bed, Mother was sent back to HUMC On Tues. (Feb.10, 09) for the trach to be properly changed by Dr. Brian Benson, the EENT doctor who did the original procedure, who then changed it to a size 8 Portex.  She was also given a CAT scan (which was reported to be “OK for her age”), and an EEG (with reported “abnormal activity” – which could have been induced by the psychiatric drug, or bed electricity, or coughing/suctioning activity etc.)  She later underwent another EEG at Kindred (June 12), which showed NO signs of seizure activity.

 

Due to the negligence at Select, Mom was in a deep coma, and prior to discharge, the Select wound nurse (Debbie, don’t know her last name), examined her, and showed me the large red mark on her back.  This was only two days following the trach accident, and right when her PT was erroneously halted.  Debbie then warned me, “You need to watch this.”  I was not familiar with such things, and I didn’t know what she meant, but it was hardly my job to make sure that a bedsore was prevented!  Their staff of “professionals” are supposed to watch and prevent such things!  That is their job, and there is NEVER ANY EXCUSE for a bedsore, especially a 13cm sore on a five-foot-tall woman!

From Tuesday – Friday, Feb. 10-13, at HUMC, Mom received a much larger Size 8 trach from Dr. Benson, which is what should have been done in the first place.  She came in and out of consciousness, and when her eyes were open, she would grimace in pain and suffering and confusion and fear over what had happened to her.  Mom was always very facially expressive, and I could plainly see the fear and pain in her eyes, and I felt useless to help ease her pain.  This was traumatic for BOTH of us!

 

Mom was diagnosed with anoxic encephalopathy, caused by these medical errors.

 

***Under the NJ Patient Safety Act, this brain injury is a Reportable Event regulated under the list of “Never Events:”

***Product or medical device related:  Death, or loss of body part, disability associated with device malfunctions

At HUMC, she had a EEG and CATscan, ordered by Dr. Patricia Klein, a very abusive neurologist, who had no bedside manner whatsoever and who was incredibly rude to me despite the post-traumatic state that I was (and remain) in.  Dr. Klein erroneously gave Mom huge does of Depacon, an epileptic drug, claiming it would “wake her up,” but instead had the opposite effect, and which later compromised Mom’s kidneys, leading to her passing. 

 

Dr. Klein originally saw Mom at Select, both before and during the following three days at HUMC. Mom was sent back to Select on Friday, Feb. 13.  That day, I pressed Dr. Klein as to therapies, treatments etc would help Mom’s injury.  Dr. Klein’s response was, “there’s nothing, now I’m too busy to talk to you.”  This was clearly negligence, abuse, and Select’s mishandling of Mom’s case, especially on the part of Dr.Klein.  Mom continued in a coma for three weeks.  I ordered the epilepsy drug DC’d, and I fired Dr. Klein

 

Dr. Klein had a particularly abusive bedside manner, and behaved carelessly and inapproprietly in her handling of my Mother’s case.  At both Select and HUMC, her rudeness and abusive manner towards myself were inexcusable.  On Feb. 17, I had Dr. Klein removed from my mother’s case.  Later that day, she appeared at Select, and was promptly told by Dr. Pantagis, Mom’s attending physician, that her services would no longer be needed.  Without seeing my Mom, she then proceeded to write notes in Mom’s chart, and then charged for a “service.”  I refuse to pay for her fraudulent actions and inappropriate treatment of both my Mother and myself.  I reported this to Tonia Smith at Medicare, who stated that this is Medicare Fraud, and an investigation is underway.

 

A formal complaint for action against Dr. Klein’s license was filed with the Consumer Affairs Board of Medical, State of NJ, and also with HUMC Consumer Affairs.  Neither “investigation” found any evidence of wrongdoing.  Later, at Kindred Hospital, Dr. Frank Gazzillo (North Jersey Neurologic Assocs P.A., 973-942-4778, 973-942-3210), a very compassionate and intelligent neurologist, told me that my assessment of Dr. Klein’s treatment was correct, that I was correct to fire her, and that my introducing alternative treatments such as acupuncture and holistic supplements was the right way to go for Mom.  He also sent a letter to the NJ TBI Fund (Mom’s File # 5881, case worker was Paula Walsh, HIP, 201-996-9422, ext. 19) to wit, encouraging the continuation of such holistic treatment. Hence ***I wish to also file separate legal action against Dr. Patricia Klein for her negligence, inappropriate treatment of my Mom, and also for Emotional Distress towards myself.

 

Back at Select, Mom was even further negligently treated.  Before this incident, I had become an integral component of Mom’s PT, as was encouraged early on by the Select PT staff to bring her dance music and work with her, which I did every day, making careful appointments with PT to be there with her music at the times they would come to her room.  On Feb. 13, I asked the head of PT when Mom would resume therapy.  PT refused to work with her.  Select also failed to give Mom a pressure-relief inflatable mattress.  This was clearly a huge mistake, as brain injury recovery requires that the patient receive stimulation and movement, regardless of age, in order to prevent pressure sores. 

 

***Within three weeks of the trach event, Mom developed a 13-cm Stage-Four pressure sore, which was debrided at Select on March 1, 2009, by plastic surgeon Dr. Matthew Coonce, (908-810-8550).  This horrible bedsore happened at Select due to negligent care and lack of PT. Mom had NO such wound of any kind upon admission! Pictures of the stages of this bedsore, including ones I took myself, are available upon request. 

 

*** Under the NJ Patient Safety Act, this is a Reportable Event regulated under the list of “Never Events:”

***Patient Care Management related events: Stage IV ulcers acquired after admission.

 

As a dancer who moved with grace and beauty flexibility into her late 70′s, this was devastating.  Mom was also fully able to hear and comprehend words, as I would often speak to her normally, and she would react facially appropriately to my words, and would also react to music.  She clearly retained ALL her faculties following the accident, but was ROBBED of her ability to communicate and to move on her own.  As one who knows her better than anyone else, I know this to be true.  Following this horrifying preventable event, Mom’s graceful dancer’s arms were often contorted into decorticate positions. 

Mom should have been referred to a Traumatic Brain Injury facility, such as Helen Hayes or Kessler, but Select never bothered to mention nor consider this.  It was only after I began doing research into TBI and registering Mom for the NJ TBI Fund, that I learned of such facilities.  It is not my job to know this, Select supposedly are “professionals” and should have done this.  Upon inquiry, in May, the brain injury specialists at Helen Hayes told me that Mom would have gotten PT there even in coma, regardless of her age, and how important PT is to prevent bedsores and other complications.  By the time I had done sufficient research, it was already three months post-injury, and both Helen Hayes and Kessler told me that it was already too late for her to begin treatment, and that Mom should have been transferred to a TBI facility immediately upon injury!  Had Mom been properly transferred to such a facility, she would have recovered more of her functions and would not have contracted the bedsore.  By May, I registered Mom for the NJ TBI Fund, and inquired into Helen Hayes and Kessler, both who specialize in brain injury.  The brain injury specialists at both had said that Mom should have been brought in immediately post-injury, to receive PT, stimulation and proper therapy to avoid bedsores, but three months post-injury was already too late, as her bedsore was at Stage 4, due to Select’s negligence. 

 

This was outright negligence and ignorance on the part of Dr. Klein, who clearly is not knowledgeable in the areas of TBI.  Mom should have been seen by a neurologist who specializes in TBI, however, Dr. Klein is the ONLY neurologist listed on staff at this Select.  Ironically, Select lists TBI as one of its of treatment specialties – however Select caused Mom’s TBI, and then neglected to properly treat the injury that Select caused.

 

Following her return to Select from HUMC on Feb.12, Mom received two units of blood within one week, as her hemoglobin level dropped to about 6.  Upon her admittance to Select on Jan 28, I had brought her vitamin supplements to be sure that she continued to receive them, as Dr. John Totaro, her regular MD for years, had prescribed iron 2x/day for her.   Select neglected to give her the iron, because they claimed they “forgot,” so Mom became anemic. 

 

At Select, Mom was protein-deprivedand mal-nourished.  She was not given adequate protein supplements, which also dropped her albumin levels dangerously and she became dehydrated.  Select’s “nutritionist” (don’t recall her name, but she’s a heavyset fair-haired older woman) is useless and clearly knows nothing about proper nutrition.  To counter this condition, Select’s Dr. Stranbrandt, staff doctor, erroneously chose to give her large IV fluid bags, which ballooned her weight from her normal 120 pounds on her 5’1” frame to 150 pounds though she was tube-fed, and swelled her limbs to the point of weeping profusely and gushing fluid through split skin, causing further infections and more breathing difficulties.  I had to instruct the doctors to turn off these IV bags.  Select clearly did not properly balance her chemistry.  This made her more prone to infections, and the added weight strained her heart and made it difficult to wean her off the vent. Her limbs continued to weep, and to be edeamic due to lack of movement. 

 

I quit my twenty-year career to care for Mom, learned coma stimulation and became her ONLY therapist.  I brought in holistic treatments and nutrition, which helped Mom much more than anything Select did.  Mom gradually opened her eyes and became more responsive.  She was facially expressive and was aware of what was going on around her. She was able to feel pain, and demonstrated such when moved in certain ways.  She felt the pain of her bedsore.  She was able to hear, as she responded well to my voice and my words to her, but Mom never spoke again nor barely moved on her own. She could not respond, and I could see how frustrating this was for her. She could no longer lift her arms, hold my hand nor express herself as she always had.  This is Robbery!  This was devastating for both of us, who for many years danced professionally together. 

 

Mom’ huge pressure sore should have received a wound VAC at Select, which she later received at Kindred, but was not offered one, as Select do not have any.  Had I known of such a thing as a wound VAC, I would have demanded one for her, but it is not my job to know this.  As Select’s finances report substantial profit increases over last year, Select can certainly afford wound VAC’s, and should have them.  Select’s wound care is substandard and outdated, as reported in other Select facilities.

 

I was deeply traumatized and in shock from seeing my Mother in a coma, as she had never been in that state before, so I cannot recall names of specific nurses from that day.  Select refuses to name the nurse and CNA responsible for the turning incident, despite that legal counsel has repeatedly instructed Select to do so.

Following Mom’s event, the entire Select staff was walking around looking very guiltily at me, and this didn’t register with me immediately, as I was not experienced in these matters nor medically trained.  I just was filled with hope and prayer and belief in Mom’s strength of constitution and character to pull thru this, and how was I going to help her. 

That morning of Feb. 8, I had a painful exchange with Bobby, the charge nurse from the night before, (don’t know his full name, he is South Asian/Indian).  I asked him if Mom was going to wake up, and he suddenly pulled a very guilty and sheepish expression and said, thru a contorted face, “We hope.”  Later that day, Noela, the day charge nurse, was also acting and looking guilty, and offered to give me sandwiches from the staff room, as I had not eaten all day, whilst was waiting for Mom to wake up/be transferred to HUMC for a proper trach change.  I reused to leave Mom’s side, and was in terrible mental anguish from all this.  Later, when I finally went home to try and rest, I could not sleep and called the nurses’ station in the middle of the night to ask if Mom had awakened yet.  Mom’s night nurse simply said to me, “Pray.”  Very guilty indeed.

Dr. David Orr (201-498-1311), attending pulminologist at Select at the time, informed me that Mom’s trach accident was not due to her physiology (or her capacity to breathe), but due to technical troubles with the trach, and that the trach was mishandled (negligently).”  This clearly indicates that RT Julio Bautista acted alone and is at fault for the trach accident.  Mr. Bautista did not consult with a physician nor with a senior nurse prior to his improper changing of the trach.  He acted independently and without physician’s order to downsize this trach.  He is clearly responsible, along with the nurse and CNA who carelessly turned Mom without attention to her improperly downsized.

I only got jumbled answers from Select staff and guilty blank looks whenever I asked for explanations.  I never received any straight answers.  When I pressed for how long Mom lost oxygen, I was told it was max 5 minutes, although it was considerably longer, closer to 15 minutes, long enough to damage her brain permanently.  Suzanne, a better RT, revealed to me that Mom’s vent alarm was repeatedly sounding, and it took all that time for staff to get to her.  They did not act quickly enough, and admitted it.  Select clearly and purposely concealed this information to avoid justified legal action, and blatantly lied, obstructing justice and withholding evidence. 

 

At Select, Julio Bautista never gave me a straight answer when I questioned him about the events of the night of Feb. 7-8 when he changed the trach.  He spoke in circles and made no sense and was obviously covering his tracks.  He made a very bad judgment call, and he knew it   His Spanish accent made him difficult to understand, and no matter how many times I asked him to clarify, he never cooperated.  He is clearly guilty, and should lose his license and be deported back to Spain.

When I questioned an RT at HUMC about it, she said plainly that a small trach such as a 4 should only be used for someone who was nearly fully weaned off vent, and then not by itself but used in conjunction with either an oxygen placement in the nose or other form of resp. support.  Further, the stoma surrounding the trach was not closed enough to keep such a small trac in place when going suddenly from a 6.  Several RT’s concurred that Julio’s actions were clearly inappropriate.

Following this event, the care that Mom received at Select continued to be negligent, and this was even more difficult as she could no longer speak for herself nor express her needs on her own.  In a vegetative state due to the brain injury, Mom was completely at the mercy of these often careless and negligent staff.  For example, occasion, when my Mom had her second bout of C-diff and diahrrea caused by antibiotics, we had to wait for over TWO HOURS for Mom’s diaper to be changed, which caused her to get e-coli in her UT, a serious UTO infection, on top of the C-diff.  I repeatedly asked the nurse to have her changed, and the excuses given were that the aides were “too busy with other patients,” short-staffed etc.  Unacceptable!

 

Another time, a male nurse assigned to her (don’t recall his name) was not agreeable to come to her aid when I saw she needed help and I asked him.  He got off-handed and complained to me that I was “bothering him too much.”   Then he should not be a nurse!

 

One day in early March, Mom was put into a sitting-up position, which she could not handle at that point, and she was slumping over and barely able to get oxygen form this slump-over, even on the vent.  The nurse assigned to her that day had not worked with her before, and I saw that and hit the ceiling!  Remember, Mom could no longer communicate her needs, and she had always been clear verbally, until the trach event.  I notified Bobby, the charge nurse (same one who had been on duty during the trach accident), and demanded a different nurse be assigned to Mom immediately.  I told them that if this happened again, that I would remove her from there myself and take her home to receive care, regardless of how ill she was. 

 

These sorts of things went on regularly, and the doctors who came in to make rounds often did not communicate well with each other and the care was never consistent.  There were virtually NO doctors on staff full-time, except a “house doctor” or two, and they were not the most helpful nor best informed.

 

On top of all this, as I tried to attend to and manage Mom’s care, the Select admin staff bullied and intimidated me relentlessly about papers and care management etc, chasing me down the halls when I was trying to speak with doctors and get information. 

 

On March 18, 2009, Mom was transferred from Select into Chateau (same building as Select) for vent weaning and rehab, where she suffered additional horrors.  (A separate complaint for against Chateau was escalated to the supervisory revue level; see DOH Case # 37001.)  In June, Mom was admitted into Kindred Hospital, (L-TAC) Wayne, NJ, where her care was much better and more comprehensive.  Kindred incorporated the holistic nutrition that I brought in, and did much better at balancing her chemistry, but the damage done by Select’s negligence was clearly done.  I wish Mom had never been at Select, and have advised everyone I know not to admit loved ones into any Select facility! 

 

Julio Bautista also was working nights at Kindred.  I found this out in July one evening, when I stayed late with Mom, to the end of visiting hours (8pm), when I ran into Julio in the elevator as I was leaving.  He was just coming in to begin his night shift, and we said a cordial hello.  But then I realized how awful that he is working there (since he admitted to being a part-time per diem at Select, thru an agency, and not a regular Select employee).  I was suddenly very angry, and I raced back upstairs, and reported to the charge nurse and head of RT (Victor) that under no circumstances was Julio to be assigned to care for Mom.  Julio and I got into a brief heated conversation, and I informed him that the matter was being investigated.  He never was assigned to Mom at Kindred, and was told to work the other side of the floor, away from her.

At Kindred, Rick, an older more experienced RT who came on board in mid-July, upon my telling of Mom’s story, said gravely and darkly to me: “Things happen at Select.”  He had heard about lots of mistakes and negligence at Select thru the rounds of RT work. 

Mom was definitely sensitive to the bedsore pain and to pain in general following the accident with the trach.  Every time I would exercise her, as I was asked to do by PT staff, Mom would often wince in pain when turned a certain way, or when her bedsore area was worked on.  She clearly was sensitive to touch and stimulation, as I learned comastim at Kindred, and would use several different stimuli on her such as heat, cold, wet, strong tastes, scents etc, all of which she reacted to strongly and was often awake , just non-verbal and not moving. 

Despite Kindred’s very good care, the errors Mom suffered at Select proved permanent.  Mom passed away at St. Joseph’s ICU on Aug. 6, 2009.  All Mom wanted was to come home, and this was stolen from her.  I lost Mom twice: at her brain injury, and again at her passing.  Her passing her been ruled a Wrongful Death, and legal action has been taken.

 

I am under doctors’ care for depression, anxiety, and sever PTSD, due to this horror and to the abuse and intimidation we were both subjected to.  My blood pressure continues to be a problem and I am taking therapy — all at my own expense, as I have not been working since I quit my career to care for Mom, and have no health insuranceMITSS.org defines my condition thus:  “Medically Induced Trauma is an unexpected outcome that occurs during medical care that negatively impacts the emotional well-being of the patient/.family.”  My therapist (Maryanne Olsen, Ph.D.) feels that I have been so severely traumatized by what has happened to Mom that I may never fully recover.  So both our lives have been wrecked.

 

***Under the NJ Patient Safety Act, these named Reportable Events regulated under the list of “Never Events” must be properly reported and published.

 

***In accordance with the NJ HEAL (Healthcare Errors Accountability Law), signed into law August 2009 by former Gov. Corzine, Select must publish these errors as PSI’s, and reference Select’s billing for such. 

 

Our horrible experience, as well Select’s poor record of care chronicled in The NY Times (Feb.2010), has led to Investigation by the Senate Finance Committee (ongoing since March 2010) regarding such.  Select Medical has is also the subject of many lawsuits for securities fraud and employee grievances, in addition to many for medical malpractice.  Select Medical Corp. clearly is profit-centered, NOT patient-centered, and their profits have increased significantly yearly.  Former employees of Select have come forward publicy to report that Select’s regular modus operandi is to cut corners on patient safety and care in order to increase profits.  This clearly violates Medicare guidelines and Patient Safety. 

 ***In accordance with the NJ HEAL (Healthcare Errors Accountability Law), signed into law August 2009 by former Gov. Corzine, Select must publish these errors as PSI’s, and reference Select’s billing for such.
 
The Senate Finance Committee and the Government Accountability Office launched a Congressional Investigation into Select Medical Corp (3/10).  The Report of this Investigation into L-TAC hospitals prompted by NY Times articles (2/10) on the poor quality of care and suspicious deaths associated with Select Medical Corp. The GAO report of the Investigation into L-TAC hospitals is below.  Lengthy, but please note in the Conclusions section that there ARE CONCERNS about the quality of care in these small in-between hospitals, and that further investigations are needed:
 
http://www.gao.gov/new.items/d11810.pdf
 
 
In addition to many lawsuits for medical malpractice,  Select Medical has is also the subject of many lawsuits for securities fraud and employee grievances, which I can provide details of upon request.  Select Medical Corp. clearly is profit-centered, NOT patient-centered, and their profits have increased significantly yearly.  Former employees of Select have come forward publicly to report that Select’s regular modus operandi is to cut corners on patient safety and care in order to increase profits.  This clearly violates Medicare guidelines and Patient Safety.
 

***** In light of these errors, I call to question Select’s hospital accreditation and Medicare Funding.  Since Medicare provides 70% of their funding, with all due respect, I request and strongly recommend a full Medicare Inspection by CMS of this Select facility.

 

I filed Complaint (4/11) against Julio Bautista (NJ Resp. Care Lisc.# 43ZA00356200, exp.3/31/12), stating that his per diem employment from Select and Kindred and any other facility that may contract his services must be terminated, that he must be stripped of his license and credentials, that his agency must take disciplinary action, and deportation proceedings be initiated against him, as he is an immigrant originally from Spain.  NJ OAG Enforcement Bureau sent an Investigator to my house (5/11) who did along investigation, after which a hearing was help on March 7, 12, where Bautista was found not to be at fault.

 

**In March 2012, I was informed by the RT Board that, following an Enforcement Bureau Investigation into Mr. Bautista’s care of Mom, that a Dr. Karim, whom I never met nor heard of, was present in the room when Mr. Bautista downsized Moms to from Size 6 to Size 4This begs the question of who actually ordered the trach to be so downsized – was it in fact Dr. Karim or Mr. Bautista?  This was never communicated to me, and was omitted from the medical records that I and our attorney received upon ordes.  This is in clear Violation of CMS and Joint Commission Disclosure Policy and NJ State Law

 

Select has repeatedly refused to identify the nurse and CNA who carelessly turned Mom between 9:00 and 9:30 AM on the morning of Feb. 8, 2009.  I filed Complaint (4/11) with the Board of Nursing, stating tha their employments must be terminated, and each be stripped of their credentials.  Should they be contracted thru agencies, those agencies must be notified and take punitive action.  Deportation proceedings must be initiated against each, should they be foreign-born.  OAG found them t=not to be at fault, but I disagree due to the Bedsore issue.  The matter is under appeal.

 

Dr Patricia Klein (NJ License # 25MA03348500, 1976-77,Active) must be removed from Select’s roster of staff physicians, due to her inappropriate handling of Mom’s care.  Her license must be brought to question.  I filed Complaint (5/11) with The American Association of Neurology (ongoing).

 

It is about time that these so-called medical “professionals”(sic) stop treating older people and patients in general like nothing more than pieces of meat, and start treating and considering the WHOLE person:  her intellect, history of good health habits and diet, sensitivity to pain etc. 

 

My Mom, my only family and Best Friend, Vera Links Eliscu, a fourth-generation law-abiding tax-paying American, must not have died in vain

 

Thank you for your attention to these matters.

 

Respectfully submitted,

 Veronica James

Daughter and only family of Vera Eliscu

vjames@gmail.com

 

 

 

Noah’s Story: Please Listen By Tanya Lord, MPH, PhD

April 17, 2012 in Patient Advocacy

Noah’s Story: Please Listen By Tanya Lord, MPH, PhD

Original URL: http://www.psqh.com/marchapril-2012/1197-noahs-story-please-listen.html

   
  Noah Lord

Communication in healthcare—provider to patient, patient to provider, and provider to provider—is at the heart of improving quality and patient safety. This is the story of my son Noah, whose experience with the healthcare system 13 years ago inspired me to work toward making positive changes in hospital care. His story is interspersed below with my present-day commentary about what I now understand about how poor communication contributed to his death. I hope Noah’s story inspires patients, families, and providers to communicate as effectively as possible and helps other patients and families avoid harm.

January 25, 1995
Boston, Massachusetts

Noah was born healthy and happy, but as an infant and toddler he did not babble or verbalize in the way that was expected.

1997
Boston, Massachusetts

Noah’s speech development continued to be somewhat delayed, which was determined to be due to periodic hearing loss caused by multiple ear infections and chronic fluid in both ears. He was referred to an otolaryngologist in Boston who recommended placing tubes in Noah’s ears to allow fluid to drain. The doctor also considered whether Noah might have sleep apnea for which he would recommend removing his tonsils and adenoids. A sleep evaluation determined that Noah did not have sleep apnea, and therefore only tubes were necessary. They were put in place during uneventful surgery.

**********************************

Please visit the “original url” to read the full article:

About the Author:

Tanya Lord was a special education teacher when Noah died. After his death she read The Institute of Medicine’s report To Err Is Human and realized that the errors responsible for her son’s death were not unique. This created a desire and determination to better understand and work towards improving health care. Currently she has completed a master’s degree in public health and a PhD in clinical and population health research and is completing a post-doctoral fellowship. Lord shares her personal and professional experiences in presentations and workshops for medical staff and students focusing on the importance of effective communication with patients before and after an error. She also is a co-founder of The Grief Toolbox (www.thegrieftoolbox.com), which offers tools to help those along the grief journey. Lord may be contacted at Tanya.Lord@umassmed.edu.

@ShahinaLakhani: #AmandaTrujillo’s case, why is it a wake up call for the #healthcare system & the society #nurseup

April 17, 2012 in Amanda Trujillo

@ShahinaLakhani: #AmandaTrujillo’s case, why is it a wake up call for the #healthcare system & the society #nurseup:”If you have been reading about the case of Amanda Trujillo, an Arizona nurse who is under investigation for providing information to a patient, you must be wondering about the state of our healthcare system.
How did our healthcare system come to this? What is the solution?
As I read all the blogs and ponder what people are saying I am disheartened and happy at the same time. Disheartened at some people’s arrogance and happy about a few good people (hopefully a lot of good people) who have refrained from pointing fingers and tried to look at the big picture.”
http://throughlifeanddeath.com/amanda-trujillos-case-wake-call-healthcare-system

For more information on Nursing Advocacy, Fundraising, Petitions in Support:

Main hub: http://www.nurseup.com/

Andrew Lopez, RN
Nurseup.com, A Nursing Advocacy Organization
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