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Dec 27
2013

Shut Off Alarms Lead to Patient Death

alarms A nurse at an Iowa VA hospital admits to turning off alarms in a continuous monitoring unit, leading to the death of a patient, says Frenkel & Frenkel.

The death of an Army veteran at an Iowa VA hospital could have been prevented had a nurse not turned off alarms designed to monitor patient conditions. One of the alarms shut off was designed to monitor blood-oxygen levels in patients who required continuous monitoring.

Patient Death

Michael Deal, an Army veteran who required continuous monitoring due to disabilities he suffered when he was injured by shrapnel from exploding land mines while in combat in Vietnam, died on March 29, 2013. According to an email from respiratory therapist Jason Swenson, which was sent to others at the hospital five days after Deal's death, numerous interventions were available that could have prevented his death had he or a physician known about the drop in blood-oxygen. According to the email, he and a colleague, Daryle Jager, found Deal "unresponsive, ashen, pale, cyanotic," and a "code blue" was issued. A review of patient monitors later found that all of the alarms in the unit had been shut off for approximately three hours. During that time, Deal's blood-oxygen slowly dropped form a normal level of 90 to a dangerously low level in the 30s. The patient's low blood-oxygen level lasted for at least 45 minutes before Jager and Swenson realized what had happened.

Nurse Admits Turning Off Alarms

At a hearing to determine unemployment benefits, nurse Bernard Nesbit admitted that he had turned off the alarms. He stated that he did so because the alarms were "always going off," even when the patient was not in distress. At the hearing, hospital Human Resource Specialist Greg Smith testified that there had been other disciplinary issues with Nesbit, and that the nurse was on a "last chance agreement" with the hospital when the alarm incident occurred. However, when Smith was asked if any patients died due to the alarm incident, he testified that a patient had passed away, but that there was no indication that intervention would have made a difference in that death.

State Licensing Board

During the unemployment hearing, Smith was asked if the hospital had reported Nesbit's actions to the state licensing board, and Smith admitted they had not, but that they planned to do so. According to Smith, the matter had to be approved by the VA before the state licensing board could be notified. Nesbit's unemployment request was denied based on what the hearing officer determined was "overwhelming" evidence that he had shut off the alarms in the unit.

When medical malpractice is suspected as the cause or contributing factor in an incident that causes injury or death, a medical malpractice claim may be in order. Contact Dallas-Fort Worth lawyers at Frenkel & Frenkel to schedule a free initial consultation regarding an incident where injuries may have been caused or worsened by medical malpractice.

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alarms
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malpractice