Description of Event or Problem · 1
A MALE ADMITTED IN 2007 WITH RESPIRATORY FAILURE SECONDARY TO RECURRENT ASPIRATION PNEUMONIA, SEPTIC SHOCK, END STAGE RENAL DISEASE REQUIRING HEMODIALYSIS, HYPOTENSION, CAD STATUS POST CABG, SEVERE PVD, CHF, AND RAPID A.FIB WITH RAPID VENTRICULAR RESPONSE. PATIENT WAS INTUBATED IN THE EMERGENCY DEPARTMENT WITH A CHEST X-RAY SHOWING RIGHT LOWER LOBE INFILTRATE. THE PT UNDERWENT BRONCHOSCOPY ON THE SAME DAY, WITH REMOVAL OF LARGE AMOUNTS OF SECRETION. PATIENT IS AN DNR. A WEEK LATER, PATIENT CONDITION CONTINUES TO WORSEN. PATIENT IS POSITIVE MRSA. ECHOCARDIOGRAM SHOWS SEVERE LEFT VENTRICULAR DYSFUNCTION WITH AN EJECTION FRACTION OF 10%, AORTIC STENOSIS, MOD/SEVERE MITRAL REGURGITATION. BP RANGES FROM 80-90 SYSTOLIC ON MULTIPLE PRESSERS PROGNOSIS POOR. AT 0415 ON THAT DAY, PT WAS GIVEN BED BATH AND TOTAL LINEN CHANGE. AT 0445, RN IN ROOM PREPARING TUBE FEEDING, VENTILATOR ALARMED SEVERE OCCLUSION, RN ATTENDED TO ALARM IMMEDIATELY, RN NOTED CLAMP ON WATER TRAP CONNECTED TO EXPIRATORY LINE OF VENTILATOR TO BE IN THE OPEN POSITION (NORMALLY WOULD HAVE BEEN CLOSED). REGISTER NURSE EXANIMATED VENTILATORY TUBING AND FOUND INSPIRATORY TUBING TO BE FILLED WITH WATER. PATIENT WAS REMOVED FROM VENTILATOR AND WAS BAGGED. PATIENT WAS SUCTIONED RETURNING COPIOUS AMOUNT OF WATER. PATIENT WAS FOUND TO BE IN PEA CONFIRMED ON ULTRASOUND AND PRONOUNCED DEAD.