Case study

Please answer me following question from case

1) summery of the case

2) Parties involved in this case

3) Potential cause of problems

4) How you would handle this issue differently

Case

Introduction

Was Janet Nastori's death at age 17 preventable? Following an incident which almost took her life two years earlier, Janet's service agency identified remedies to prevent similar occurrences in the future. However, the corrective actions identified were either not implemented or not sustained.

Background

Janet was the third of Mr. and Mrs. Nastori's five children. During birth, she suffered severe anoxia, resulting in profound mental retardation, cerebral palsy, spastic quadriplegia and a seizure disorder. As an infant, Janet suffered from numerous ailments, including asthma and recurrent pneumonias, and was frequently hospitalized.

As her parents could not care for her multiple, everyday medical and developmental needs, at age four, Janet was admitted to a nursing home for children in a neighboring state. In addition to medications for her seizure disorder, Janet required a J-tube for feeding; adaptive equipment (braces and wheelchair) for proper body alignment and mobility; range of motion and positioning therapy for her spastic quadriplegia; and the use of a Bi-pap machine and pulse oxymeter for sleep apnea. Due to her chronic respiratory difficulties, Janet also required nebulizer treatments and postural drainage accompanied with chest percussion several times daily.

Postural drainage with chest percussion is intended to improve respiration by preventing the accumulation of secretions in the lungs, or facilitating their removal, through the use of gravity and mechanical action. The individual is placed in a series of reclining positions with the head and upper body inclined somewhat downward as a staff member gently percusses the individual's chest and/or back with a cupped hand. After being percussed, the individual remains in each position for about three to five minutes to allow secretions to drain. Secretions are suctioned from the mouth and nose as needed.

When Janet was nine, she was transferred to an Intermediate Care Facility in New York, closer to her family, which remained involved in her care. The single story, twelve-bed residence was designed for medically frail children. It offered round-the-clock nursing coverage, in addition to direct support staff, as well as in-house educational and specialty services, such as physical and other therapies. Although residents attended various medical clinics in the community, an agency physician would visit the facility periodically to assess and/or follow up on clients about whom nursing staff had concerns of a non-emergency nature.

Janet's plan of care in the residence addressed her wide range of medical and developmental needs and through her teenage years she remained relatively stable, considering the complexity of her needs. She was dependent on staff for all activities of daily living, was aware of her surroundings and, although non-verbal, expressed pleasure or discomfort through facial expressions and vocalizations. She particularly enjoyed music and humming along to familiar tunes.

The First Incident

One evening, just shy of her 16th birthday, Janet received one of her daily respiratory treatments. After having been percussed, Janet was left alone in her bedroom for an undetermined amount of time, lying in an inclined, head down postural drainage position. A passing nurse discovered Janet in this position, turned her over and discovered she was blue and not breathing. Thick saliva was found in her mouth and nose.

While 911 was being called, nursing staff performed deep suctioning, to clear Janet's airway, and administered oxygen. Within minutes, Janet's coloring returned and she began breathing on her own. Responding EMS personnel monitored Janet's vital signs, which had returned to normal, and determined that transport to a hospital was not necessary.

The direct support staff member who was assigned to Janet was docked one day's pay and given a written counseling memo for having left Janet alone during postural drainage. The agency's investigation, completed three days later, revealed that this staff member was assigned to perform postural drainage for Janet and two other individuals, in their private bedrooms, all at the same time. The reason she left Janet alone was to tend to the other individuals. The agency investigator recommended that management and nursing staff review and modify assignments and schedules for postural drainage treatments to ensure that individuals receiving such care are not left alone. Staff were also to be instructed that they should not leave a client unattended during postural drainage.

The Incident Review Committee (IRC) met about one month later, accepted the findings and recommendations of the investigation without question, and closed the case the same day. The IRC did not schedule any review or follow up on the recommendations to ensure their implementation and appropriateness, or success in reducing risk of harm to individuals.

The Second Incident

One evening, approximately two years later, Janet was again found alone in her room in a postural drainage position. She was cyanotic, not breathing and had secretions around her mouth. A faint pulse was detected, but disappeared. While 911 was being called, nursing and direct support staff initiated CPR and administered oxygen. Responding EMS took over resuscitation efforts and transported Janet to a local hospital where she was pronounced dead. Based on the autopsy findings, Janet's healthy clinical picture in the days and weeks prior to death, and the circumstances surrounding her demise, the Commission concluded that the most likely cause of death was anoxia due to airway obstruction caused by secretions.

The agency's investigation into Janet's death determined that the staff member assigned to Janet left her alone in a postural drainage position, after having percussed her, to tend to two other individuals assigned to her, one who needed to be changed and put to bed and a second who needed tracheotomy care. As she left Janet, this staff member called out to a second staff member asking that he check on Janet, which he did about five minutes later after he was done tending to another individual. It was then that he found Janet in distress and called for help.

The staff member assigned to Janet told the investigator that she had not received formal training on postural drainage; she was shown how to do it by another direct support staff member. She also stated that she was never told not to leave individuals alone while they were receiving postural drainage; she claimed that it was usual practice in the home to leave the individuals, checking on them periodically, while tending to other individuals. The staff member's comments on training and practices in the residence were echoed by other staff. The agency could find no documentation that this staff member had been trained in postural drainage.

The staff member was demoted and assigned to another residence.

As a result of the agency's investigation, written policies on postural drainage, including the expectation that individuals receiving such are never to be left alone, were developed, and a hands-on training program for direct support staff, to be conducted by nursing staff and respiratory therapists, was put into place. The agency also rearranged staff assignments and schedules for postural drainage so that no individual would be left alone -- a corrective action called for in the first incident involving Janet two years prior. In its investigation, however, the agency did not probe why recommendations stemming from the first incident were not implemented or sustained.

Discussion

Serving on the front lines of service delivery, direct support staff are consumers' life line to quality care.

In Janet's case, they woke her, bathed her, clothed her, fed her, positioned her, monitored her and sang to her, filling her brief and fragile life with the care, compassion and companionship on a daily basis, that no one else was able to provide.

Unfortunately, as illustrated in Janet's case, direct support staff are often made the "fall guys" for flaws in the systems in which they work, while underlying issues, which set them up for failure, are left unattended.

After Janet was first found in distress, the staff member assigned to her was punished for leaving her alone, despite the fact that this staff member was tending to other individuals for whom she was also expected to care. A recommendation made at that time -- to adjust care-giving schedules to prevent similar situations -- evidently was not implemented and/or followed up to ensure that it was.

This set the stage for a second, fatal incident. Janet was left alone again, went into distress, and was discovered too late to be saved. Again, a direct support person was punished. The agency never questioned why recommendations from the first incident were not carried out. And, it was only after the fatal incident that the agency instituted protections which should have been in place long ago - and certainly after the first incident - such as:

developing written policies and procedures concerning postural drainage;

* providing training for direct support staff by professional staff;

* realigning schedules of care to ensure that direct support staff can accomplish tasks they are assigned without compromising safety and quality of care.