Assignment Task:
Prior to the PMHNP seeing the patient, he had been examined and treated by two physicians and another PMHNP employed by the facility. Notably, a formal psychiatric evaluation with a history and physical examination (H&P) were not completed within the first 48 hours of the patient's admission to the facility, which was the facility's policy. Incidentally, the federal regulatory requirement for behavioral/psychiatric health facilities is to have a completed H&P within 60 hours of admission. The delay was probably due, in part, to the patient being admitted over a holiday weekend when staffing levels were lower.
The PMHNP's first contact with the patient was at 9:00 a.m. on day three of his admission, which was a holiday. During the assessment, the PMHNP documented the patient's complaints as difficulty sleeping, nausea, vomiting, diarrhea, abdominal cramps, muscle aches, chills, runny nose, sore throat, cough and goose bumps. She noted his temperature was 99.8 degrees Fahrenheit, pulse oximetry 99 percent on room air, blood pressure was 190/88 and a respiratory rate of 22. During the physical assessment, she recorded that the patient's tonsils were beefy red with positive exudate, but lungs were clear on auscultation. While reviewing the patient's chart, she noted that a few of the admission orders had not been completed. She re-ordered a throat swab for streptococcus and added a complete blood count (CBC) to the order. When the insured PMHNP asked the staff about the missing orders, she was told that staffing levels were low due to the holiday weekend, and the nursing staff was doing the best they could at the moment.
The patient requested that the PMHNP discontinue his current sleeping medication and prescribe zolpidem10 mg. Knowing that 10 mg is above the recommended dose of zolpidem, the PMHNP verified that the patient had previously been prescribed zolpidem 10 mg during his last admission, so she agreed to prescribe the zolpidem. In addition to the zolpidem 10 mg, the PMHNP increased gabapentin 300 mg twice-a-day to 600 mg twice-a-day, increased dicycloverine from 20 mg twice-a-day to four times-a-day and added tizanidine 2mg three times-a-day. The insured PMHNP left the facility approximately 2:00 p.m. and this is the last contact she had that day with the patient and the staff.
Later that afternoon, the nurses documented twice that the patient's temperature was 102.7 degrees Fahrenheit but that his lungs were clear. At 9:00 p.m., the patient received his night-time medications, which included the updated doses and the newly added medications. During the night-shift nurse's assessment, she documented that the patient's throat was visibly inflamed, his tonsils were red with scattered white patches, but he had clear lung sounds bilaterally to all lobes.
Unbeknownst to the staff, and against the facility's policy, at approximately midnight, the patient's roommate gave the patient a peanut butter sandwich and a soda. Food and drinks are prohibited in patient rooms as a safety precaution to prevent aspiration in cases where a patient was at risk of suffering a seizure due to withdrawals. At approximately 1:00 a.m., the patient was found in severe respiratory distress and nonresponsive. EMS was called, and the patient was transported to the hospital.
The patient was diagnosed with sepsis, acute respiratory failure and aspiration pneumonia. As part of the treatment measures in the emergency department, a drug screen was performed. Consistent with the patient's drug abuse and the medications he was given at the facility, he tested positive for heroin, cocaine, zolpidem and gabapentin. However, the patient also tested positive for benzodiazepine, more specifically alprazolam. The patient had not been prescribed any benzodiazepines while at the facility, and his admission drug screen was negative for benzodiazepine use. Upon learning of the patient's positive benzodiazepine result, the facility performed an investigation.
The patient spent four weeks in the intensive care unit (ICU), three of those on a ventilator. While in the ICU, he developed a MRSA infection from a large sacral pressure injury and was diagnosed with pulmonary hypertension. Due to the pulmonary hypertension and sepsis, he developed a hemorrhagic disorder that resulted in the need for additional treatment for several pulmonary emboli.
Upon discharge from the ICU, he remained hospitalized for an additional five weeks. Upon his discharge from the hospital, he was admitted to an inpatient rehabilitation facility to undergo physical and occupational therapy. Currently, the patient lives with his parents and requires assistance with his activities of daily living. He has been disabled due to cognitive impairments and right ventricular heart failure.
During the facility's investigation of the incident, it was discovered that the patient likely aspirated after eating the peanut butter sandwich and soda given to him by the roommate. The roommate reported being concerned about the patient and gave him the food because he wanted "to see him eat and drink since he was feeling sick."
The facility discovered there was a patient selling/distributing contraband alprazolam bars. The bars had been smuggled into the facility by a visitor and distributed by a patient. It is assumed that the patient in this case ate at least two bars, which was the cause of the drug screen being positive for benzodiazepine.
One year after the incident, the patient/plaintiff filed a lawsuit against the PMHNP and the behavioral health/detoxification facility. Allegations against the insured PMHNP included failure to order the appropriate medication, untimely management of a behavioral health patient, and failure to timely respond to patient's concerns related to the treatment plan. The demand from the patient was $1.4 million for physical and mental anguish, physical disfigurement and physical impairment, as well as past and future loss of earnings and medical and healthcare expenses incurred for the treatment of his injuries both past and future. Additionally, his medical costs related to the incident were greater than $3 million.
Question:
Q1. Identify the defendants and areas of negligence in this case.
Q2. Identify/list screening tools for substance use disorders that would be appropriate in the case of this patient.
Q3. Reflect on this case and identify/describe what you would have done differently as the PMHNP.
Q4. What do you think the verdict was and why?