Shut Off Alarms Lead to Patient Death
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.
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.
My mother was admitted to TRMC in Mount Pleasant on March 31 with Covid Pneumonia. She spent two weeks in Covid ICU and then tested negative. She was then moved to ICU. On April 14, she was scheduled to move to Texarkana to a long term acute care. Just before she was due to leave, my sister arrived at the hospital. This was around 8:15 a.m. Upon entering my mother’s room, she found our mother in excruciating pain and her oxygen levels were in the 50s. Before this, her O2 levels were in the mid 80s so they felt good about transferring her. After several minutes, my sister had to go into the hallway and call for nurses and the doctor. This is when it was discovered that her monitors had been turned off at the ICU desk. Her lung had collapsed and she lay there for at least thirty minutes in pain and with limited oxygen to her brain. The doctor had to do an emergency bedside procedure where he punctured her chest with his finger and inserted a chest tube with very little anesthesia. Of course, this saved her life but it should not have been an emergency procedure. The monitor should have caught this and it should have been a procedure where she was put completely under and experienced no trauma. On April 15, she was put on a ventilator. By the end of the month, she was transferred to Fort Worth and she passed away on May 4.