Description of Event or Problem · 1
DATE AND TIME OF OCCURRENCE: 2008, 5:50AM. DATE FACILITY WAS INFORMED AND BY WHOM: LPN SUPERVISOR REPORTED INCIDENT TO REPORTER, DON AT 6:20 AM. CAN RESIDENT IDENTIFY PARTIES INVOLVED: NO. IS RESIDENT CREDIBLE: NO, -NON-VERBAL- INJURY: ON COMFORT MEASURES, RESIDENT EXPIRED, DNR. TREATMENT: NURSES ATTEMPTED TO REMOVE ORAL SWAB WITH SUCTION AND TWEEZERS -PER ORDER FROM FIRST CALL TO MD- BUT HAD NO SUCCESS. RN ASSESSMENT: RESIDENT WAS HAVING NO RESPIRATORY ISSUES, RESIDENT REMAINED PINK, RESPIRATION EASY, AND NO INDICATION OF DISTRESS. MD CALLED; ORDER TO SEND TO HOSPITAL. EMS ACTIVATED. RESIDENT NEVER EXHIBITED SIGNS OF RESPIRATORY DISTRESS. RN LEFT RESIDENT ROOM TO GO TO THE NURSES STATION WHILE STAFF LPN LEFT THE NURSES STATION TO GO TO THE RESIDENT ROOM. WHEN LPN ENTERED THE RESIDENT ROOM SHE FOUND THE RESIDENT HAD EXPIRED. PARTIES INVOLVED IN THE INCIDENT AND TITLE/RELATIONSHIP: LPN NURSE SUPERVISOR AND LPN STAFF NURSE. SYNOPSIS OF INCIDENT: RESIDENT HAD AUDIBLE UPPER AIRWAY CONGESTION -DEATH RATTLE- THAT COULD BE HEARD FROM THE HALLWAY. STAFF NURSE AND LPN SUPERVISOR WENT INTO RESIDENT ROOM TO SWAB HIS MOUTH OUT. A LARGE AMOUNT OF THICK WHITE PHLEGM WAS RETRIEVED. LPN SUPERVISOR SWABBED THE MOUTH A SECOND TIME AND THE SWAB STICK BROKE. THE RESIDENT DID NOT BITE THE STICK -HAS NO TEETH-. MD WAS CALLED. NURSES ATTEMPTED TO REMOVE ORAL SWAB WITH SUCTION AND TWEEZERS -PER ORDER FROM FIRST CALL TO MD- BUT HAD NO SUCCESS. RN ASSESSMENT: RESIDENT WAS HAVING NO RESPIRATORY ISSUES, RESIDENT REMAINED PINK, RESPIRATION EASY, AND NO INDICATION OF DISTRESS. MD CALLED; ORDER TO SEND TO HOSPITAL. EMS ACTIVATED. RESIDENT NEVER EXHIBITED SIGNS OF RESPIRATORY DISTRESS AND NEVER GASPED FOR A BREATH. RN LEFT RESIDENT ROOM TO GO TO THE NURSES STATION WHILE STAFF LPN LEFT THE NURSES STATION TO GO TO THE RESIDENT ROOM. WHEN LPN ENTERED THE RESIDENT ROOM SHE FOUND THE RESIDENT HAD EXPIRED. CONCLUSION AFTER INVESTIGATION AND INTERVIEWS: INCONCLUSIVE, HOWEVER, THE RESIDENT DID EXPIRE DURING THE EPISODE WHERE THE ORAL SWAB STICK BROKE AND REMAINED IN THE RESIDENT UPPER AIRWAY/BACK OF MOUTH. THE RESIDENT DID NOT ASPIRATE ON FEED, THE PHLEGM THAT WAS SWABBED WAS THICK WHITE, NOT TAN -THE COLOR OF FEED-. THE RESIDENT NEVER SUFFERED FROM RESPIRATORY DISTRESS, NEVER GASPED FOR AIR. THE ORAL SWABS USED IN THE FACILITY APPEAR TO BE TOO SMALL TO CAUSE AN OBSTRUCTION IN AN ADULT. WITH THE INCREASED CONGESTION NOTED THE RESIDENT COULD HAVE HAD A MUCOUS PLUG THAT OBSTRUCTED. WITH THE QUICK SUDDEN DEATH IT COULD HAVE BEEN A CARDIAC ISSUE. THE RESIDENT WAS ON COMFORT MEASURES AND THE NURSE STATED THAT A DEATH RATTLE IS WHAT ALERTED THEM INTO HIS ROOM; THE INCIDENT COULD HAVE HAD NO EFFECT ON HIS DEATH. FINAL ACTION TAKEN: ALL BLUE ORAL SWABS WERE PULLED OFF ALL UNITS. MEDLINE CALLED AND NOTIFIED OF INCIDENT. REPORTED TO THE DOH. FAMILY MADE AWARE OF INVESTIGATION. ORAL SWABS ARE USED DAILY ON RESIDENTS WHEN INDICATED. DATES OF USE: UNKNOWN. DIAGNOSIS OR REASON FOR USE: ORAL CARE.