Report: Nurse unhooked COVID-19 patient’s oxygen
Indiana investigating death at nursing home
INDIANAPOLIS – The nurse had watched the nursing home resident suffering with breathing complications from COVID-19. She saw him repeatedly try to remove his oxygen mask and asked him if he “wanted to let go and go to Heaven” so he could “fly with the angels.”
She then removed his oxygen mask without a doctor’s order. The man died.
The alleged incident inside Wedgewood Healthcare Center in southern Indiana is detailed in a state health inspection report reviewed by The Indianapolis Star. The report says the patient, identified only as “Resident B,” had COVID-19 and had endured days of aggressive oxygen treatment.
The nurse, who is not named in the inspection report, later described the ordeal in social media posts. “I just want y’all to know the hardest thing I’ve ever done in 28 years start a patient on O2 for 4 days 12 LPM. with a non-rebreather mask,” she wrote, describing the oxygen treatment of the resident. “I asked him on day 4 if he’s tired he said yes I said do you want me to take all this off for you and let you go and fly with the angels and he said yes.”
The post continued: “I took it all off of him I went in the hallway and I cried and I let him go and he passed away ... after I left.”
According to the inspection report, no further care was provided to the resident for nearly eight hours until his death. Inspectors cited the facility for abuse and neglect, failure to notify about changes in the resident’s condition, and other violations.
Neither the resident’s doctor nor family was told about the oxygen mask until after the resident’s death, according to the inspection.
The facility learned of the nurse’s actions days later after another employee saw the nurse’s social media posts and sent screenshots to the nursing home’s executive director.
“It’s just heartbreaking in a whole new way,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a national group that advocates for nursing home residents.
Clarksville Police Chief Mark Palmer said the case had been referred to the state attorney general’s office. Beth Defalco, spokeswoman for the nursing home operator, Ohio-based Communicare, confirmed that the attorney general was investigating and that the company was cooperating “at every step.”
The nurse’s action is an extreme example of the stress and challenges nursing home workers faced dealing with COVID-19. At the time, Indiana was at the first peak of coronavirus cases.
Wedgewood has been hit particularly hard by the virus. At least 70 residents have contracted COVID-19 and 20 have died at the 124-bed facility owned by Columbus Regional Hospital.
Going into the pandemic, Wedgewood had the lowest possible staffing rating from federal regulators – “much below average” – and was in the bottom 15% for total staffing nationally.
The Wedgewood nurse told inspectors she had been having a “terrible” week when she removed the oxygen from the resident. She said she had been taking care of more than 40 COVID-19 patients at the time and had forgotten to contact the doctor.
In its citation, state inspectors said the potential for harm started when the nurse removed the resident’s oxygen but persisted for weeks later because the facility needed to continue monitoring staff who were working more than 40 hours a week.
Even though the nurse took action on her own, the facility is ultimately responsible for the care of the residents, Mollot said.
In response to the state’s inspection, the facility said it would update its policies, increase its oversight of resident progress notes and complete regular audits of resident conditions and assessments.