So DOH descended on us yesterday—“DOH” being the NYS Dept. of Health, “us” being James Square Nursing Home, and “yesterday” being October 22, 2015. They arrived early in the morning to do their annual inspection and totally scared the shit out of the staff. DOH is the licensing agency and they can put you out of business if they are so inclined. And virtually everybody who administers anything here knows that I’ve filed dozens of complaints; whether that’s had any impact or not I cannot say.
DOH will be here for five working days on their annual visit. This is an unannounced visit, however, their last annual unannounced visit was October 23 and 24, 2014. It is not exactly a drop-dead shock to the James Square staff that they are here now. Before 10:00 a.m. of the first day, I’ve got my name on DOH’s list of people who have got something to tell them.
DOH only has been here once in the past year. According to the big orange book of Statement of Deficiencies, “Specifically, for Resident #1 an investigation was not conducted and reported to the NYS DOH when a physician’s order to change a tracheostomy tube (trach) to a larger size was not clarified or implemented. This resulted in no actual harm with potential for more than minimal harm . . .”
“More than minimal harm” is the government’s way of saying “it could have fucking killed the patient.”
So here’s what happened: The patient had brain damage. The physician’s hospital Discharge Summary didn’t say anything about the patient having a trach; James Square’s nursing Admission Report said the patient had a #6 trach.
“Note: if unable to replace the trach tube with the same size, insert the next smaller size . . .”
[None of this makes any sense because only the odd-numbered pages of the report are in the Statement of Deficiencies book; even-numbered pages have been omitted.]
So somebody saw an order to change the patient’s trach from a #6 to an #8. The Somebody saw the order, “was unsure how to change the trach and made the decision to wait and have the next shift do it.”
“A [patient’s] trach should not be changed to a larger size in the nursing home”
Policy was that RNs could change trachs when the [registered respiratory therapist] was not on duty.
The unit manager said he had not seen the physician’s order to change the trach to a #8. He said he would have changed the trach to an #8 if he’d seen the order.
The [nurse practitioner] said that she wrote the order to change the trach to a #8 uncuffed on the advice of a third respiratory therapist (RRT #3), who said she would do it.
When re-interviewed, RRT #3 said she didn’t know nothin’ about nothin’. She didn’t remember having any conversation—nothin’ about trach brand, size, smaller, larger–actually, she thought they should have called an ear, nose and throat doctor.
The physician stated that he expected to be notified if an order was not carried out. The physician said he read the nurse practitioner’s order to change the trach to a #8 and signed off on it. He did not know the patient had a #6. He “made an assumption” that the patient already had a #8.
So there you have it: the hospital discharge physician didn’t even mention a trach. The James Square admitting nurse noted the trach but not its size. A nurse practitioner—maybe or maybe not after talking to a respiratory therapist—wrote an order that she shouldn’t have for a larger trach. The nurse didn’t know how to change it and passed the buck to the next shift. The nurse manager never noticed the order. The doctor—who never looked at the patient—signed off on it because he was just plain careless. And six months later, DOH investigated it and was told by the director of nursing that “an investigation was not done, as the resident’s trach falling out was a medical event and they do not investigate medical events.”
Everybody was lazy, incompetent or careless; nobody was doing their job, and nobody asked why.
And now we are gathered together for the next annual certification survey.
