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Henry Ford HospitalShawnee Mission, KS |
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Kae of Overland Park, KS December 5, 2008
On 4/12/08, I took my father, Anthony Frank, to your Urgent Care Center in Oak Park Mall as he had been having back pain severe enough to keep him from eating. The doctor ordered Xrays of the pelvis. The MA attempted 4 times to get films dark enough even though this was causing my father pain. The doctor reviewed the films and told me my father had an impacted fracture of the right hip presumably from one of the falls he had earlier in the week. The doctor advised us to go to SMMC ER and he called the triage nurse to alert her and we left by car with the films. Two staff members did come to get my father out of the car and put him on a gurney. The ER doctor, Dr Miller, ordered more films and did his assessment and determined it was not a hip fracture but a compression fracture of L1. Dad was in pain and was given 8-10 mg of morphine in divided doses. He did not get relief from his pain. The nurse Becky then gave him 1 mg of Dilaudid IV. Dad did go to sleep and I noted that he was looking dusky. He had a BP cuff on but no pulse ox. I got another nurse who apparently was floating to the ER and said his ears were blue. Her response was Yes they are-is that normal? no it was not. She then attempted to put on the pulse ox and could not get the monitor to work. She and another nurse, Nancy, came into the room. Nancy got the pulse ox working and Dad's sats were about 77% and dropping. They dropped to about 38%. A Dr Boysnik came in, opened his airway and asked Nancy to give Narcan and begin to bag Dad. I should mention that his blood pressure had dropped to 80s systolic. The narcan took effect and Dad's sats came up and he woke up. My concerns are as follows: Dad is 88 years old with COPD. Would it not be prudent to monitor his sats when giving narcotics? We had 3 nurses in about 3 hours. Communication seemed to be poor between the nurses as only the first one knew Dad had COPD. None of them applied the sat monitor. No nurse came in to see if his pain was relieved. Is it protocol to assume that the medication worked if the patient does not complain? Follow up assessments are not warranted? When giving narcotics to an elderly person with COPD, it seems that a nurse should come in occasionally since those drugs do cause respiratory depression. Had a nurse come in most likely they would have noticed the change in color. Again, lack of follow up assessments. The only employee to sanitize their hands was the respiratory therapist. Perhaps it is also acceptable to use the PRN adapter on the saline lock without wiping it with an alcohol wipe at your facility? SMMC has been our family's hospital of choice. I took my daughter there on 2/14/08 with pyelonephritis and she received excellent care. I am certain that the ER was busier when I brought my Dad there on 4/12. Does that excuse poor nursing care? I shudder to think what could have happened had I not noticed his color change. The failure to monitor my father by your staff could have cost him his life. Quite frankly I am terrified to leave him at your facility without someone there to monitor the staff. I have little trust in the abilities of the staff there. And I am unsure as to what to say to rectify this. I would appreciate speaking to someone in authority over this matter. Sincerely, Kae T MSN, RN Dad home for about 1 week; began having severe back pain. We took to Shawnee Mission ER on 4/26. They evaluated and started him on Oxycontin and sent him home. He had confusion (Dad was NOT ever confused). He began hallucinating. We had called his doctor on 4/27 and basically begged her to admit him and then they did-he was diagnosed with UTI which he most likely had the day before but they never checked. On 4/28 they found he had pneumonia. Dad died on 5/4/08 (except the death certificate says 5/2/08 and I am frankly too tired to argue that point. The bottom line is he is dead). The death certificate says he died from sepsis.
I had Kansas Foundation for Medical Care-the QIO for Kansas-conduct an investigation on the care my Dad received. They found that the care given in the ER on 4/13 did not meet the standard of care. Advertisement
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