Week 8 Assignment q

Historical Case Study #1: When Nursing Care and More Complex and Adequate Training and Supervision Are Absent

ENVIRONMENT AND HISTORY

This case took place in a small rural community of 8000 people. Mr. Kenny Salamino was a developmentally and physically disabled 32-year-old man. He had lived most of his life in a group home with seven other residents and was cared for by a staff of two unlicensed assistive personnel (UAP) 24 hours a day.

Ms. Marsha Mitchell, a licensed practical nurse whose title was “Medical Director,” had worked at the group home Monday through Friday, 8 am to 5 pm, for 7 years. Ms. Rose Sinclair, a registered nurse, served as “Consultant.” Nurse Sinclair was employed to “be a resource” and provide a course entitled “Assistance With Medications Course for Unlicensed Assistive Personnel.” The owner of the facility, Mr. Brian Adams, did not live at or maintain an office at the facility. He hired the staff and expected the registered nurse and the licensed practical nurse to manage the resident care.

The state board of nursing in which the facility was located received a complaint from the Department of Health and Welfare. Mr. Salamino had died after admission to the hospital, and the state's surveyors from the Bureau of Facility Standards had investigated the circumstances of his death. Over a period of 6 months, Mr. Salamino had lost 40 pounds during which time the nurses had not assessed his health care needs or provided for adequate medical or nursing interventions. The bureau's investigation determined that the events that led to Mr. Salamino's death were due to lack of fiduciary responsibility of Practical Nurse Mitchell and Nurse Sinclair who, the report asserted, should be held accountable for Mr. Salamino's death.

THE NURSES' STORY

I have been a registered nurse for 10 years. I worked full time in a small hospital in a nearby town for 9 years as the supervising registered nurse. When I decided to work part-time, I chose to drop back and work in a less restricted environment than the hospital. The administrator of the group home hired me as the “Registered Nurse Consultant,” and my responsibilities included teaching to new unlicensed assistive personnel a course entitled “Assistance With Medications Course” and providing to the licensed practical nurse 24/7 support face to face or by cellular phone.

My contract specified that I was to be paid for 24 hours of work every 3 months. I did not receive an orientation to residential care/group home, federal, and/or state regulations.

The first indication I had that Mr. Salamino was having a problem was when Practical Nurse Mitchell called me and said that Mr. Salamino had just returned from the hospital with a new jejunostomy tube (J-tube). She said that she thought Mr. Salamino should have been discharged to a skilled nursing facility, but his physician, Dr. Fred Stark, sent him back to the group home because he thought Mr. Salamino would receive better care there. Dr. Stark worked with Practical Nurse Mitchell and the patients in the group home. They knew and loved Mr. Salamino.

I asked Practical Nurse Mitchell if she could handle the J-tube. She said she could, and thus I did not go to the group home to assess Mr. Salamino or to confirm Practical Nurse Mitchell's competency. I did not believe this was part of my job.

THE LICENSED PRACTICAL NURSE'S PERSPECTIVE

I could tell Mr. Salamino was losing weight over several months. I didn't become concerned at first because he continued to feed himself and didn't appear to be hungry. After several months, I called his doctor and he told me to bring Mr. Salamino in for a checkup. Dr. Stark was concerned about Mr. Salamino's weight loss and ran some tests. He had something wrong with his digestive tract and wasn't absorbing his food.

Dr. Stark arranged for a consult with a surgeon and that's when they decided to insert a stomach tube. Mr. Salamino was in the hospital for 2 days and was then transferred back to the group home. He was able to swallow and drink liquids. He didn't have a pump for his feedings when he arrived, so I called and ordered the pump and the liquid feeding solution that Dr. Stark had ordered. I didn't worry too much about the fact it took 4 days to start the feedings because Mr. Salamino continued to drink liquids.

When the pump and feeding solution arrived, I hooked it up but couldn't get the pump to run. I called Dr. Stark who arranged for me to take Mr. Salamino to the emergency room and meet the surgeon, Dr. Hari Harimoto. Dr. Harimoto discovered that something was wrong at the insertion site on his stomach. He repaired the insertion site and sent Mr. Salamino back to the group home. The aides and I gave Mr. Salamino his feedings as Dr. Harimoto ordered, but he developed a fever, was readmitted to the hospital about 2 weeks later, and died the same day.

When I looked back on the events that took place, I felt I was left to do everything myself. I wished Nurse Sinclair would have been more involved in what was going on, but she said she was not hired to see the residents. I know we gave Mr. Salamino better care than he would have gotten at the nursing home. They have too many patients and not enough nurses.

THE ADMINISTRATOR'S PERSPECTIVE

I have owned this facility for 15 years and never had a problem until this happened. Practical Nurse Mitchell is a good licensed practical nurse and handles things perfectly fine. I don't see any reason to have to pay a registered nurse to do what Practical Nurse Mitchell, a licensed practical nurse, can do on her own. I didn't see any reason to orient the registered nurse or licensed practical nurse to residential care/group home regulations. They are supposed to take care of the residents.

CASE ANALYSIS

This case demonstrates the classic example of the common expectation that residential/group home care does not require the level of nursing skill and attentiveness that is required in a hospital or skilled nursing facility. This expectation persists despite the fact that residents change in their care needs, and the home may not be able to keep up with the technical care demands of these changes. This owner-established care supervision plan was inadequate given the nature of the changes in the care the patient required. Several actions were inadequate in this series of events regarding the decisions that affected the patient's well-being. The practice breakdown elements included the following:

1The administrator of the group home did not provide orientation for the registered nurse immediately after her arrival. Consequently she was unaware that the State Regulations for Residential Care Facilities required that a registered nurse assesses patients on a regular basis to identify any health care needs that may be developing and to refer the patient for medical care as needed. It was only when the patient died that the state surveyed the facility and discovered the lack of supervision of a registered nurse.

2The administrator failed to provide adequate resources for the registered nurse and licensed practical nurse in their respective roles. The registered nurse was only paid for 24 hours of work in a 3-month period. She understood that her role was to provide the course “Assistance With Medications Course” for newly hired unlicensed assistive personnel, but this responsibility alone took more than the 24 hours for which she was paid. She did not understand that she was in a role that required her participation and direction for the care of the patients in the facility. She did not recognize her role as a “registered nurse consultant” to be “anything more than a registered nurse available on the cellular phone 24 hours per day.” She was not expected by administration to assume responsibility for assessment of the patients and/or to collaborate with the licensed practical nurse and physician.

3Practical Nurse Mitchell had the title “Medical Director,” which led her to believe that she was to make all decisions related to patient care. The licensed practical nurse was reluctant to call the registered nurse when she had concerns. She did contact the physician, but she did not identify the patient's health issues until the patient required hospitalization. The health care system in which the licensed practical nurse and registered nurse practiced did not design, mandate, or pay for the support and guidance that a registered nurse should have provided.

4After the first hospitalization, the patient's physician discharged his patient to the group home. The physician believed that the patient would receive better care in his “home,” where the staff was familiar with him, rather than refer him to a skilled nursing facility that could provide the skilled care he required. However, this group home was not adequately prepared to provide the skilled nursing care he needed.

The licensed practical nurse did not doubt her ability to administer medications by common routes and to provide care to two or more patients. But the evidence in this case did not address the competencies required for tube feeding and recognizing malnutrition. Further, the licensed practical nurse was slow to contact the physician regarding the patient's emerging physical changes, which could have been due to either a reluctance to call the physician and/or her lack of assessment or awareness of the dangerous level of weight loss and malnourishment.

Both nurses in this case were not aware that their individual levels of nursing education applied in this setting. The descriptions of their positions defined the relationship between the registered nurse and the licensed practical nurse. The licensed practical nurse was “in charge,” and the registered nurse was hired as a figurehead to meet the administrator's interpretation of the requirements for licensure of a group facility. These institutional policies established the scenario that eventually resulted in a patient's death. The licensed practical nurse assumed responsibility for all patient care but did not have the skills or support from the registered nurse to identify the patient's initial life-threatening weight loss, and later the need for timely initiation of his tube feedings. She continued to deal with the situation alone rather than contact and consult with the registered nurse and physician to determine the actions needed. Because the registered nurse had never worked in residential care before and was unaware of the federal and state requirements for residential care, she assumed that the duties as written in her position description were appropriate. Based on these duties, she did not assume a supervisory or active collaborative role to support the licensed practical nurse. The registered nurse and the licensed practical nurse did not question the scope of the duties in descriptions of their respective positions, nor did they look to the Nurse Practice Act and Administrative Rules to identify the roles their state board required for each respective nursing license or question their “positions” at the time they were hired. The registered nurse was content to have minimal collaborative responsibility and limited hours. The licensed practical nurse did not recognize that she lacked sufficient knowledge and training to provide the more skilled nursing care involved in tube feeding a patient through a jejunostomy. Further, the licensed practical nurse was flattered by her title and did not question the fact that she was not appropriately educated and competent to manage and provide adequate nursing care without support.