Nursing Quality Indicators
SCENARIO
Mr. J is a 72-year-old retired rabbi with a diagnosis of mild dementia. He was admitted for
treatment of a
... [Show More] fractured right hip after falling in his home. He has received pain medication and
is drowsy, but he answers simple questions appropriately.
A week after Mr. J was admitted to the hospital, his daughter, who lives eight hours away, came
to visit. She found him restrained in bed. While Mr. J was slightly sleepy, he recognized his
daughter and was able to ask her to remove the restraints so he could be helped to the bathroom.
His daughter went to get a certified nursing assistant (CNA) to remove the restraints and help her
father to the bathroom. When the CNA was in the process of helping Mr. J sit up in bed, his
daughter noticed a red, depressed area over Mr. J’s lower spine, similar to a severe sunburn. She
reported the incident to the CNA who replied, “Oh, that is not anything to worry about. It will go
away as soon as he gets up.” The CNA helped Mr. J to the bathroom and then returned him to
bed where she had him lie on his back so she could reapply the restraints.
The diet order for Mr. J was “regular, kosher, chopped meat.” The day after his daughter arrived,
Mr. J was alone in his room when his meal tray was delivered. The nurse entered the room 30
minutes later and observed that Mr. J had eaten approximately 75% of the meal. The meal served
was labeled, “regular, chopped meat.” The tray contained the remains of a chopped pork cutlet.
The nurse notified the supervisor, who said, “Just keep it quiet. It will be okay.” The nursing
supervisor then notified the kitchen supervisor of the error. The kitchen supervisor told the staff
on duty what had happened.
When the patient’s daughter visited later that night, she was not told of the incident.
The next night, the daughter was present at suppertime when the tray was delivered by a dietary
worker. The worker said to the patient’s daughter, “I’m so sorry about the pork cutlet last night.”
The daughter asked what had happened and was told that there had been “a mix up in the order.”
The daughter then asked the nurse about the incident. The nurse, while confirming the incident,
told the daughter, “Half a pork cutlet never killed an [Show Less]