Report: Nurse unhooked COVID-19 patient’s oxygen
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 IndyStar, part of the USA TODAY Network. Local police and the nursing home operator, Ohio-based Communicare, confirmed to IndyStar that the attorney general was investigating.
The report says the resident, 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 changes in the resident’s condition, among other violations.
Neither the resident’s doctor nor the 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 only 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 told IndyStar that the case had been referred to the state attorney general’s office.
A spokeswoman for the attorney general’s office said she “could neither confirm or deny” whether the case was being investigated.
Beth DeFalco, spokeswoman for 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 across Indiana faced dealing with COVID-19.
At the time, Indiana was at the first peak of coronavirus cases, both inside its nursing homes and in the general public.
Wedgewood was among the facilities hit particularly hard by the virus. At least 70 residents have contracted the coronavirus, and 20 have died at the 124bed 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.
“The nursing home is responsible for the actions if its staff and for maintaining an environment where the staff is well-trained about residents’ rights and appropriate care and treatment,” Mollot told IndyStar. “This is a system with a lot of checks and balances, and a lot of checks and balances were missing for this to occur.”
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. It also said it would track hours by position to identify staff working overtime and monitor staff to make sure they get enough rest.
In an email to IndyStar, Communicare’s DeFalco defended the care the company provided.
“Communicare staff have worked tirelessly to care for our residents during this global pandemic and we have followed all state and federal safety guidelines,” she said, although several Indiana facilities managed by the company were cited for violations last year. She also said that “nursing homes are being held to a higher scrutiny than hospitals and ERs.”
Kelsey DeClue, public relations director for Columbus Regional Health, which owns Wedgewood, called the situation heartbreaking and said Communicare “worked in a diligent, timely manner to correct all deficiencies identified as a result of the (inspection).”
The nurse could face criminal charges. Indiana has no assisted suicide law, and helping a person end their life can be a crime.
Legislation that would allow people with a terminal illness to request medication from a health care provider “to bring about a peaceful death” has been introduced in the Indiana General Assembly for at least the past three years. But none of those proposals have gained any traction.
Cases that are investigated by the attorney general are referred first to local prosecutors, who decide whether to pursue the case or hand it off to the attorney general. In the latter case, the attorney general will identify the appropriate charges.
“It’s just heartbreaking in a whole new way.”
Richard Mollot Executive director of the Long Term Care Community Coalition