Nursing Facility Hit with Highest Fine Possible after Patient's...

Written by Elizabeth Bishop , Senior Internet News Producer A nursing facility in Sacramento County has received the most severe citation under state law after a patient died of a massive morphine overdose in ...

[The Witness]

I am a registered nurse, most of the time
I have worked the night shift. I have worked in acute care settings. Even in acute care,
medication and other errors are made that are not reported. I personally have made an effort to fill out Notification Reports, but, I know that my co-workers have often not.
There is a stigma to reporting errors that shouldn't be. We should all learn from errors and be the wiser. Not all hospital administrations react favorably to the help that they have who acknowledge errors. I worked at Methodist Hospital of south sacramento, who opereate Bruceville Terrace. This article is about a horrible medication error at Bruceville Terrace. With the amount of foreign help that Methodist hires (people who are often culturally afaid of their
superiors and fear for their job security because they have overseas families depending on them for money) it is no wonder that errors at both campuses get covered up or under reported. Methodist Hospital does not have good Labor Relations and an atmosphere of
blame creates this kind of secrecy. The overdose should have been reported immediately in this instance. So have I seen other lesser things happen that didn't get reported because the hospital liked it that way. Less paper work, less accountability, and see no evil make no changes.

[I told you so]

I contacted the Department of Health
Services, Division of Licensing and Certification (years 2001-2003) about staffing and care issues at Methodist Hospital, parent to Bruceville Terrace (where this error took place.) I also wrote the DHS in concern that Methodist Hospital was poorly tracking their Patient Controlled Anesthesia, or PCA.
I noticed that entire shifts would not document the amount of PCA medication that
a patient got. In addition, there would be no charting on the amount of medication credited to the next shift. I provided Methodist Hospital with a analysis of one patient's chart who was using PCA at long term.
I suggested that there be a better flow sheet for PCA documentation. At that time, the Medication Record was the only spot to document PCA. A tiny space. Not condusive to evaluating the effectiveness of the medication or capturing how much monitoring the PCA got that shift. About 2 weeks after reporting this concern to the state, Methodist Hospital quickly drafted a flowsheet for the PCA.
PCA is usually a narcotic and the use and monitoring of it should be taken seriously, always at least double checked. It shouldn't have taken my letter to the state to wake these people up. Narcotic injection has risks and the risks can be reduced with proper handling, proper monitoring and patient education. I was told by former Catholic Healthcare West co-workers
that this medication error was very avoidable,
and that in fact, the nurse actually thought that she was hanging an IV antibiotic and not a narcotic.(She was a fairly new hire and English was her second language.) This error not only reflects poorly on Bruceville Terrace but it reflects badly on Methodist Hospital, as
Methodist Hospital relocates nursing supervisors from Bruceville Terrace to their acute care setting. Perhaps also this nursing home was beyond their scope in this instance, and with this patient.(I don't know.)
All I can say is that I could see this coming. Thank you.

[I was warned]

The previous writter wrote "Methodist Hospital relocates nursing supervisors from Bruceville Terrace to their acute care setting. Perhaps also this nursing home was beyond their scope in this instance, and with this patient.(I don't know.)"
Employees from Bruceville Terrace are moving from BVT to Methodist in hopes of staying within the local community and CHW system and to get away from Linda Turner the incompetent director that badgers and yells at her empoyees instead of fixing the issues and giving solid direction to good nurses that a so job scared they won't stay for long. She fires or runs off well seasoned staff that knows more than she does in order to hide her incompetence! CHW should fire her!

[Nobody]

I have been a Paramedic in Sacramento for the last 13 years and an EMT-II before that.

Myself and other Paramedics used to complain all the time about SNF's.

NO ONE CARED.

Far to often I see the end results of medical mishapes. While mistakes get made accross all diciplines, mistakes seem to be higher in SNF's. Simple mistakes. Ones that are easy to correct, yet have catastrophic consequences if they are not fixed.

As a mandated reporter, I fill out the stupid APS form as required, go through the motions and follow proper protocal, knowing full well, NOTHING WILL EVER CHANGE.

I make a difference where I can, do my part in the system, and keep my side of the street clean.

I walk in, thank the SNF staff for an amazing job done, head to the room, work the code, tube my patient, start lines, push drugs and get the hell out.

[Southwest Seminars Nurse]

Come attend our Nursing Law Seminars offered by Southwest Seminars. We discuss,'chain-of-command', floating, delegation, supervision of other staff, staffing and other "hot" issues in nursing practice. Come learn how to better protect yourself and your empolyer from potential litiation. Our live, one-day interactive seminars provide quality up to date information and review "real" cases against "real" nurses. visit us at www.southwestseminars.com

[Interested_Party]

Appreciate what The Witness had to write, thanks.

[Interested_Party]

Someone should have listed to this intelligent person and this person is very right to say I Told You So to Methodist Hosptial and Bruceville Terrace. What a tough thing to have to carry around with you as a soul !!