MRS. R Case Study

Case Study:

Mrs. R is a 70-year-old widow with one moderately attentive son who lives in a different city. She is a nursing home resident with mild dementia and many physical problems who was treated in a hospital for pneumonia and then readmitted to the nursing home. Two days after her return to the nursing home, Mrs. R began to deteriorate. She developed a slight fever as a remnant of her previous infection and seemed lethargic. The team discussed this case at its weekly meeting, which was attended by the licensed practical nurse and social worker involved in Mrs. R’s care; the registered nurse was attending a continuing education program outside the building that day. One of the things discussed was Mrs. R’s expression to several staff members that she did not want any “heroic efforts” to be used to keep her alive. Mrs. R died that night in her sleep.

Mrs. R’s son informed the state survey and certification office about his mother’s death. As part of the investigation report, the state surveyor (a retired police officer) noted the facility had not immediately informed the physician or son about the significant changes in the resident’s condition, as required by state statue and the federal regulations. When questioned about the absence of timely notification, a licensed practical nurse told surveyors about Mrs. R’s explicit “no heroics” instruction.

Should the facility have notified the physician and the son about Mrs. R’s rapid deterioration? What could the physician and/or son have done with the information in light of Mrs. R’s expressed wishes about treatment? Is the facility’s failure to notify properly just a technical violation of the law, or is it more substantive? Should the violation be excused under these circumstances? How should the staff members have documented this series of events?