Read HISTORICAL CASE STUDY #2: Attentiveness and Surveillance and submit APA Paper , write a paper
addressing the following:
a. Describe what factors surrounding attentiveness and surveillance contributed to the outcome of this case
study.
b. What did you learn from the Case Study?
Ms. Kathy Chin had been admitted to the LTC facility in October with heart failure, bipolar disorder with
depression, constipation, history of gastrointestinal bleed, glaucoma, and discomfort. She required total care
and was not able to effectively express her needs to the LTC staff. In January she had a bowel impaction, and
Fleet enemas were administered. She was discovered unresponsive in her room the next afternoon and was
transported to the hospital. Blood work revealed that she had a urinary tract infection. She was administered
antibiotics and discharged back to the LTC facility.
Six weeks later, Ms. Chin had another episode of constipation. The day shift Nurse Supervisor, Ms. Angela
Guilarte, notified Ms. Chin’s physician, Dr. Brian Fisher. Dr. Fisher ordered an x-ray of Ms. Chin’s abdomen,
and it revealed severe constipation with fecal impaction. Dr. Fisher ordered clear liquids only and “Fleet
enemas until clear.” This was the same regime that was previously ordered and administered to Ms. Chin in
January.
A licensed practical nurse, Ms. Margaret Reyes, took the order by telephone, notified day shift Nurse
Supervisor Guilarte, documented the order in Ms. Chin’s chart, as originally received from Dr. Fisher, and on
the medication administration record [MAR] “enemas continuously until clear.” Practical Nurse Reyes, who
received the order for “Fleet enemas until clear,” questioned the order and discussed it with Nurse Supervisor
Guilarte. They determined that the enemas should be administered every 3 hours until the return was clear but
did not clarify this with Dr. Fisher or pass this information on to the next shift.
The enemas were administered over a 12-hour period by three licensed practical nurses working various shifts.
Again Ms. Chin was found unresponsive, and she was transferred to the hospital where she died 6 hours after
admission.
THE NURSE’S STORY
I came to work early that evening and was told that the licensed practical charge nurse for one of the units had
called in sick. I realized that I would have to cover the patients for the licensed practical nurse as well as
provide supervision for the other two units. I received a short verbal report from Ms. Zellner, the evening shift
registered nurse supervisor, who reported Ms. Chin’s bowel impaction and the order to administer Fleet
enemas until clear. I was told that Ms. Chin had been given three enemas prior to my shift.
It didn’t occur to me that I should assess Ms. Chin and review her orders. I started administering the
medications on the unit I was covering for the absent licensed practical nurse. About 3:00 AM, Ms. Mary
Pellagros, a licensed practical nurse assigned to Ms. Chin, came to me and said she did not feel comfortable
with the order for Fleet enemas until clear. Ms. Chin’s blood pressure was 70/56, and eight enemas had been
administered. She asked if the order should be changed. I told her to call Dr. Fisher. I also told Practical Nurse
Pellagros to ask if we should start an IV for fluid replacement and draw stat labs to check her electrolytes. I did
not assess Ms. Chin as I trusted Ms. Salamino to follow through.
Practical Nurse Pellagros later told me that Dr. Fisher repeated his order for “Fleet enemas until clear” and
“reluctantly gave an order for an IV.” Dr. Fisher refused to order stat labs. I didn’t ask Practical Nurse Pellagros
if she had informed Dr. Fisher of the number of enemas that had been administered (eight). It took several
hours for the IV fluid and pump to be delivered to the facility. I went to Ms. Chin’s room and started the IV. I did
not conduct an assessment, but Ms. Chin was responsive. At the end of the shift, I reported off to the Shift
Supervisor Guilarte and told her about the new orders that were obtained during the night. I did not report the
number of enemas given on the night shift (eight plus four), and I did not check to see if vital signs had been
documented during the night shift.
It is my understanding that the day shift administered three more enemas to Ms. Chin after which, at 1:00 PM,
she was found to be unresponsive. She was then transferred to the hospital. I trusted Practical Nurse Pellagros
to provide the care Ms. Chin required. Nurse Pellagros called Dr. Fisher and carried out his orders. I didn’t
believe it was my responsibility to challenge a physician’s order, and I didn’t believe I should call my supervisor,
the Director of Nursing, in the middle of the night.