Dehydration occurs when the body does not have enough fluids because more fluid is lost than is taken in.
With the elderly, dehydration can be caused by many factors, but studies indicate that inadequate staffing and lack of supervision are principal causes of dehydration in nursing homes.
In the following case, a nursing home resident’s death was determined to be caused by dehydration coupled with a new or existing cardiac condition that was exacerbated by her dehydration.
What led up to the patient’s death?
One day, a female resident of a nursing home was transferred to a hospital psychiatric ED due to “combative behavior and a possible altered mental state.” She also was lethargic and physically unstable.
The ED staff, who observed the patient for several hours and did lab work, decided she was medically stable but was suffering a psychotic episode. She was returned to the nursing home the following morning.
Upon her return, the patient continued to be lethargic and confused. The RN asked the certified nurse practitioner (CNP) working with her that day to evaluate the patient and asked that the patient be returned to the ED.
The CNP determined that there was no medical reason to transfer the patient back to the ED and told the RN to wait another day. It is important to note that the nursing home’s unwritten policy about transportation fees prohibited nurses from sending residents to the ED.
The patient’s lethargy and mental changes continued throughout the evening. She was administered Lorazepam twice. The following day, the same RN was assigned to care for the patient and was also acting as the nursing home’s facility supervisor. The patient was aggressive, medicated with Ativan several times, did not eat or drink anything, spoke unclearly, 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 her right side on the floor, told the RN to “leave her alone.” Two student nurse aides (STNAs) noticed the patient’s breathing was labored and thought she should go to the ED.
The RN asked the CNP several times to authorize the patient’s transfer to the ED, but was denied each time. When the RN contacted the facility director of nursing (DON), the DON deferred to the CNP’s decision.
About an hour later, the patient’s son arrived at the nursing home for a visit and found his mother on the floor and not breathing. Someone called 911, but the EMTs couldn’t resuscitate her. She was pronounced dead at the hospital.
An autopsy was requested but wasn’t done. Instead, the medical examiner relied on a review of the patient’s medical records to determine the cause of death. He determined the cause of death was due to an epileptic seizure and hypertensive cardiovascular disease was a contributing factor.
The son filed a lawsuit alleging wrongful death and violations of the state’s nursing home patient bill of rights against the nursing home (and its corporate entities) and the CNP.
The trial court’s decision
The nursing home and the CNP filed a Motion for Summary Judgment, which basically stated that the deceased patient’s son did not present evidence that they caused the death of the patient. The son argued that he had indeed presented sufficient evidence to support his claim through his expert witness.
The son’s medical expert witness opined that the cause of death was due to a “new or pre-existing cardiorespiratory disease.” In addition, the deceased’s post-mortem lab work indicated that she was dehydrated, which also contributed to her death. Despite this opinion, the court granted the nursing home and the CNP’s motions.
The son immediately filed an appeal, alleging that granting the summary judgment motions was an error. The appellate court carefully reviewed the applicable Ohio law and found that the son did submit sufficient evidence to establish an issue for the jury to decide that the failure to send the deceased patient to the hospital and the CNP’s direction to “wait and see” how the patient did, also caused her death. The trial decision was reversed, and the case was sent back to the trial court.
What went wrong with the nursing care of this patient
It’s hard to understand why the CNP had a “wait and see” approach to this patient’s medical condition. The patient’s condition clearly indicated something wasn’t right, and it didn’t improve over time.
As a CNP, it’s hard to believe that her scope of practice wouldn’t allow her to override the facility’s unwritten policy that a nurse couldn’t transfer a patient to an ED when warranted, regardless of transportation fees. Her “loyalty” to the facility overrode her legal and ethical duty to the patient. As a result, her potential liability — and the nursing home’s — is now an issue for the jury to determine.
The RN caring for the patient appeared to do all she could to get her patient transferred to the ED. She asked the CNP several times, as well as the DON. Questions do remain, however, about the RN. For instance:
- Her chain of command didn’t end with the CNP and DON. Why didn’t she notify the nursing home administrator or other corporate administrators about her requests? Why didn’t she contact the patient’s physician? These details could be shared at the trial.
- Testimony at the trial level indicated that the patient refused food and water for three days. If an IV or other nursing interventions were initiated, they may have reduced the confusion and other changes to her mental status and could’ve even prevented her death.
- Apparently patient monitoring was lacking once the RN voiced her concerns to the CNP and DON.
- Despite the patient’s continued disturbing behavior, the overriding approach was to medicate her rather than further evaluate her symptoms and get a psychiatric evaluation.
- Taking vital signs may have indicated not only the dehydration but a possible cardiovascular condition. Were vital signs regularly monitored?
Granted, the patient was not cooperative, but continued monitoring and reducing safety risks to a patient are ever-present nursing responsibilities.
What can you do if you find yourself in a similar situation?
Regardless of the care setting, if you care for elderly patients, always evaluate a change of behavior as possibly being due to dehydration and, if present, intervene immediately.
Continue monitoring the patient’s condition, including vital signs, urinary output, and cognition. Notify the physician or advanced practice nurse for additional interventions.
Not taking appropriate nursing actions to intervene when dehydration is present can result in possible liability for neglect of a patient (criminal or civil), a possible lawsuit for wrongful death (as in this case), and the possibility of a professional licensure disciplinary action by your state board of nursing.
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