Nurses' Notes at Midnight

                   Nurses Notes at Midnight




          The following is a transcription of the findings from the State of Wisconsin Department of Health and Human Services wrongful death investigation initiated by Ombudsman Harold Reimer at the request of the family of Robert Hauser Sr., resident of Sandhill Longterm Care and Respite Center of Carol’s Crossing Wisconsin. 
          Robert Hauser Sr. had been a resident at Sandhill Longterm Care Center for two months prior to the incidents in question.
          Mr. Hauser’s medical history included: Alzheimer’s, senile dementia, hypertension, clinical depression, status post radical prostatectomy June 1996 secondary to prostate cancer, failure to thrive, gastro-entero reflux disease, and a history of skin cancer. 
          The prescribed medications at the time of the incident were as follows: Aricept 10mg by mouth every night, Lipitor 10mg by mouth daily, Lasix 10mg by mouth daily, Potassium Chloride 750 mEq by mouth daily, Zoloft 10mg by mouth daily, Prilosec 20mg by mouth daily, Ativan 0.5mg by mouth every eight hours as needed for anxiety or agitation, Tylenol 1gm by mouth every eight hours by mouth as needed for pain or fever.
          Mr. Hauser’s social history included: widower, three children, seven grandchildren, thirty-five year career in sales with the World Wide Import/Export Company of Baltimore MD.  Mr. Hauser lived alone for ten years in the Chesapeake Bay area until he was no longer able to care for himself.  At which time, his oldest son, Robert Hauser Jr., moved Mr. Hauser to Carol’s Crossing, WI where Robert Hauser Jr. resides with his family.  Robert Hauser Sr. was placed at Sandhill Longterm Care facility on the locked dementia unit. 

11 May, 2003 0943:  Resident showered after breakfast with minimal assistance from staff.  Weekly skin assessment done.  Skin warm, dry and intact with poor turgor.  Mucous membranes moist and pink.  Quarter sized red area noted on left ischial tubersosity.  Site blanches upon palpation.  Moisture barrier applied to site and buttocks.  Will continue to monitor.  Medications taken at breakfast without difficulty.  At this time the resident has left the unit for the prayer services held in the main activity hall.  The resident left ambulating with a stable gait and stand by assist of staff.  – Melissa Hiemback, LPN

11 May, 2003 1115:  Resident returned to room.  Has two middle aged male visitors who identified themselves as former business associates of the resident.  The resident became agitated as evidenced by pacing and yelling verbal assaults toward his visitors.  When asked what was wrong, the resident became fearful stating “They’re gonna kill me.”  The resident was reassured of his safety.  The resident continued to yell.  The resident was directed and re-directed twice but remained in his agitated state.  Ativan 0.5mg given by mouth.  Medication was taken without difficulty.  The visitors left stating they would return at a later date.  – Melissa Hiembach, LPN

11 May, 2003 2130:  Resident yelling out in room, calling for help.  Upon entry into the room the resident was found in his pajamas pulling clothes out of his dresser.  When asked what was wrong, the resident stated, “I have to get out of here.  They’re trying to kill me.”  When further asked who was trying to kill him the resident was unable/unwilling to answer.  This nurse reassured the resident of his safety.  The resident was toileted.  Voided unmeasured amount of clear yellow urine.  Resident returned to bed with verbal encouragement and stand-by assist.  – Eva Hamel, LPN 

12 May, 2003 0320:  Resident ambulated unassisted to the nurses’ station dressed in pajamas, also wearing an overcoat and hat.  The resident carried a plastic bag filled with several clothing items.  This nurse inquired where the resident was going.  The resident asked, “When does the train leave?  I have to get out of here fast.”  When asked why, the resident replied, “They’re gonna kill me.”  When asked who was going to kill him, the resident responded, “Those fellas who came today.”  The resident was invited to sit at the nurses’ station.  Vital signs:  Temperature – 97.3 F (tympanic); Pulse – 84 (radial); Respirations – 22; Oxygen saturation 93% on room air; Blood pressure - 148/92.  After being reassured there was no one nearby who would harm him, the resident was directed back to his room with assist of one.  The resident was toileted.  Voided and had a small, soft well formed bowel movement.  (The resident) Returned to bed without further incident.  Upon review of previous entries made this day, call placed to Donna Schneider, ANP for notification of new behavioral episodes.  (I) Left a message on voicemail.  – Brenda Reich, LPN

12 May, 2003 0920:  Received call from Donna Schneider, ANP.  (We) Discussed the resident’s recent behavioral outbursts and paranoia.  No behavioral episodes noted this shift.  New orders received – send urinalysis for culture and sensitivity.  – Melissa Hiembach, LPN

12 May, 2003 1110:  Urine specimen collected via clean catch.  Specimen in refrigerator to go out with daily lab pick up this afternoon.  – Melissa Hiembach, LPN

12 May, 2003 1930:  Resident Yelling for help in room.  This nurse entered the room to find two visitors verbally instructing the resident to calm down.  They identified themselves as former business partners of the resident.  The resident repeatedly yelled, “They’re gonna kill me!”  This nurse asked the visitors how they got past the security door.  One of the visitors, who identified himself as Mr. Kidder, stated they were given the security code by the day charge nurse yesterday.  The resident was asked why he thought his visitors intended to harm him.  The resident stated, “They tried to kill me before!  That’s how I got here!”  The resident was directed to calm down and was reassured that he was in a safe place and no harm would come to him.  The resident continued to accuse the visitors of trying to harm him and was unable to calm down.  The visitors were asked to leave and complied stating they would return at another time.  The resident continued in a state of anxiety as evidenced by pacing in his room and mumbling incoherently to himself.  0.5mg ativan given by mouth.  Medication taken without difficulty.  Will continue to monitor.  – Carla Engler RN

13 May, 2003 0000:  Resident found dressed at security door attempting to pull it open and elope.  The resident also had a plastic bag filled with a change of clothes.  When asked what he was doing, the resident stated, “I have to leave.  They know where I’m at.  They’re gonna kill me.”  When asked who was going to kill him the resident responded, “Kidder and Tate.”  The resident was reassured that he was in a secure facility and that no harm would come to him.  The resident was then directed back to his room with stand by assist of one.  The resident was toileted and voided.  Resident back to bed.  The resident continued to mumble, occasionally verbalizing clearly, “Why don’t you understand?  They’re gonna kill me!”  When asked why he thought his former business associates were going to kill him, the resident stated, “They tried before.”  When asked when and how, the resident blurted, “When I was assigned to assassinate Ghadafi!  They shot me before I could get my shot off!”  The resident then pointed to the right side of his head.  Upon inspection, a surgical scar is noted on the right temporal aspect of scalp.  However, medical history dictates this area is where the resident had skin cancer removed in 1989.  The resident was reminded that he worked for an import/export company to which he replied, “That was just my cover.”  The resident was then reoriented to person, place and time, reassured of his safety and encouraged to go to sleep.  One cup of warm milk was given to the resident.  Fifty percent was taken by mouth.  Will continue to monitor.  – Brenda Reich, LPN

13 May, 2003 0648:  Two men were noted leaving the resident’s room.  Upon entering the resident’s room, the resident was noted to be lying in bed with eyes closed.  Respirations are regular and unlabored.  – Candice Rischel LPN

13 May, 2003 1100:  Resident in his room calling out for help.  Upon entering the room, the resident was attempting to enter his closet.  When asked what he was doing the resident stated, “I’ve gotta hide!  They’re gonna kill me!”  When asked who was going to kill him the resident did not respond.  This writer told the resident no one was going to hurt him and that he was safe.  The resident was assisted to his chair.  Vital signs taken: Temperature: 97.8 F, Pulse: 96. Respirations: 24, Blood pressure: 152/66.  At this time a certified nurses’ assistant entered the room to toilet the resident.  – Candice Rischel LPN

13 May, 2003 1340:  Urinalysis results back – urinalysis negative.  Donna Schneider, ANP notified of results.  – Candice Rischel, LPN

13 May, 2003  1730:  Resident in dining room refusing to eat his meal stating, “It’s been poisoned.”  When asked why he thought his meal was poisoned the resident stated, “It leaves a funny taste in my mouth.  It tastes like metal.”  This nurse explained to the resident the metallic taste he was experiencing was probably a side effect from his medication.  The resident continued to refuse his meal stating, “I’m not hungry.”  The resident was offered an eight ounce can of Ensure of which he drank seventy-five percent.  – Eva Hamel, LPN

13 May, 2003 2150:  End of shift summary.  The resident refused all offerings of food or drink throughout the shift.  The resident also refused all of his medication twice, stating, “You’re just trying to help them kill me.”  When asked who was trying to kill him the resident stated, “Kidder and Tate.”  This nurse then asked the resident who Kidder and Tate were.  At this point the resident became extremely agitated and began yelling incoherently.  The resident then struck out at this nurse with a fist, but did not connect.  The resident was directed to sit down in his chair and relax.  This nurse then left the room and closed the door as the resident continued yelling incoherently.  Evening supervisor Ron Gardner, RN notified.  Call placed to Donna Schneider, ANP to update on behavioral issues – message left.  Call placed to on-call (physician) for possible medication intervention.  – Eva Hamel, LPN

13 May, 2003 2230:  Received call from Dr. Stein.  Explained the resident’s escalating behavior over the past three days and how the resident has been refusing meals and medications.  Also reported that the resident has attempted to strike staff.  New orders received -  Ativan 5mg intramuscular (injection) Now.  May repeat one time as needed.  May restrain only to deliver medication.  Night shift supervisor Sonja Lutz, RN notified.  – Kelly Freund, LPN

13 May, 2003 2315:  Staff gathered at resident’s room to assist in restraining if necessary.  Upon entering the room, the resident was noted to be lying in bed, dressed with eyes closed breathing quickly and shallowly.  The window was open with the screen on the floor between the window and the bed.  The screen was replaced and the window closed.  The resident then grabbed this writer around the waist and pulled me on the bed.  Staff were called in to assist.  The resident was manually restrained by staff while Ativan 5mg was administered by Kelly Freund, LPN.  The resident continued to struggle momentarily before becoming unresponsive.  At this time, staff was instructed to clear the room.  Vital signs:  Temperature: 96.7 F, Pulse: 104 thready, Respirations: 36 shallow, Blood pressure: 88/56, Oxygen saturation: 90 percent on room air.  Resident unresponsive to verbal stimuli.  Groaned and moved all four extremities in response to sternal rub.  Pupils equal, round and reactive to light.  Foot of bed elevated above heart level.  Call placed to on call physician.  – Sonja Lutz, RN

13 May, 2003 2333:  Received new orders from Dr Stein – Send to Marion County Regional Hospital.  Call placed to ambulance service.  Call placed to resident’s son for notification.  – Sonja Lutz, RN

13 May, 2003 2348:  Called to resident’s room by Sarah Ludwig, CNA, who stated “I came in here and found him this way.”  This writer entered the resident’s room to find the resident lying in a supine position with legs elevated and eyes closed.  Upon further inspection the resident was found to be apniec and pulseless.  Unable to ascultate a blood pressure.  Unable to ascultate an apical pulse.  Resident has do not resuscitate orders.  Sonja Lutz, RN notified of the situation.  Ambulance service called per shift Supervisor.  Call placed to Dr Stein.  – Kelly Freund, LPN

14 May, 2003 0005:  Paramedics on scene and notified of the resident’s condition.  Received call from Dr Stein.  New orders received – time of death 2350.  Post mortem care initiated by staff.  Call placed to the resident’s son who was very upset at the news.  This nurse informed him that because the death was not witnessed, by state law the coroner’s office must be notified for investigation.  Son is on his way here.  Coroner’s office notified.  - Sonja Lutz, RN

         The coroner’s report detailed three bruised areas, one on the right deltoid muscle and one on each trapezoid muscle, all consistent with intramuscular injections.  No other abnormalities were found.  The resident’s son inquired if too much Ativan had been given, however, this was unconfirmed by toxicology.  The final determination was an accidental death of unknown etiology.
         In his investigation, the ombudsman contacted the resident’s former employer, World Wide Import/Export of Baltimore, Maryland.  The company denied having any history of a Mr. Kidder or Mr. Tate ever having been employed there.
         This case has since been turned over to the State of Wisconsin Department of Justice, Division of Criminal Investigation, Special Assignments Bureau.  At this time the case has been closed as all leads have been exhausted and no evidence of foul play has been confirmed.  None of the nursing staff were ever arrested, indicted, or investigated further.
         Sandhill Long Term Care and Respite Center was consequently under a Medicare investigation, however, no deficiencies were found regarding this incident.