 One nurse, 39 patients overnight shift, let that sink in. Here we are yet again talking about another case involving a nursing error resulting in a patient death. Welcome back to the channel everybody. For those of you who are new around here, my name is Michael A.K.A. Dr. Chalini, nine on my board certified diagnostic and interventional radiologist in New Jersey. Now I just made a video last week talking about the Radonda Vaught case, which linked up here if you haven't seen it. And afterwards I was flooded with comments and DMs asking me to talk about another case that not many people know about involving a nurse by the name of Christian Ganey. At first I didn't really look into it because I don't have too much extra time on my hands. However, I'm on vacation this week and I have a little extra time to do some research. So now you have left me no choice but to do a deep dive on this particular case, go over the details, discuss what happened, and of course give my thoughts on the case. Let's go. Okay, so let's go ahead and jump right in with the details of this case and figure out exactly what happened. And just for anybody watching, I'm getting all of this information from the CMS report on this case, which was written up around 2018, I believe. And as always, I will leave a link to this 141 page document so you can peruse it at your leisure. So Christian Ganey is a 30 year old travel nurse working for the Cathedral Village Long Term Care Facility in Pennsylvania. And just so we're all clear going forward, this case took place in 2018. During the particular night shift she was working when this event took place, she was taken care of 39 patients by herself. Just let that sink in for a minute. That's right, one nurse, 39 patients, overnight shift, let that sink in. But more on that later. Of those 39 patients was an 84 year old male that was admitted on April 9th of 2018. The patient's diagnosis included hypertension, CVA or cerebral vascular accident, also known as a stroke, which we will presume to be ischemic in nature given like 85% plus of strokes are ischemic in origin. The patient also had expressive aphasia, which may have been a result of that stroke or even a previous stroke. And by the way, expressive aphasia is basically when patients have trouble speaking or they may have difficult producing coherent spoken language. However, their comprehension is relatively maintained. So what we were always taught in school and this doesn't always follow the textbook but they can understand it but what comes out is broken and jumbled. Of note, this patient also had no code status documented which is kind of weird all together because almost everybody who walks in the door for any hospital or long-term care facility has their code status documented immediately. It is in every single patient's chart I've ever worked with at every hospital I've ever been in. It's like in big letters, code status, DNR, full code, DNI, et cetera, et cetera. And one of the first questions asked to a patient when they come into any hospital or long-term care facility is what do you want us to do when your heart stops? And that is their code status. And for those patients who are demented or delirious or can't speak or can't provide their own answers there's usually a document that accompanies them or they have a family member document the code status. The patient also had a feeding tube which I will presume again to be a gastric feeding tube which the patient was supposed to be fed 16 hours per day. During the patient's short stay he experienced four separate falls ranging from 9.45 p.m. on April 9th through 1.55 a.m. on April 12th which is a period of three days, yay math. On April 12th, 2018 at approximately 11.30 p.m. the patient was found lying on the floor next to his bed. Facility documentation related to this fall showed that the patient had an unwitness fall and had a laceration to the right temple of about one by one centimeters and the same laceration on the right shoulder as well and an abrasion on the knee. After this unwitness fall, the nurse, Miss Ganey and a nursing aide transfer the patient to a wheelchair and brought him to the lobby or near the nurse's station so they could monitor him. I guess since maybe this patient had so many falls and they were covering so many other patients they wanted to keep a close eye on him so that this didn't happen again. That's just me reading between the lines not true documentation. At this time they did notify the overnight physician and started the neuro checks based on the facilities protocol. So this particular facilities policy on neurological evaluation dated last approved on February 18th of 2015 revealed that any resident with the potential for head trauma injury or having an acute change in level of consciousness will receive 72 hours of neurological evaluation following notification of the physician. So, so far, so good. In addition, the policy indicated that the neurological assessments were to be completed as follows. Every 15 minutes for the first hour followed by every hour for the next three hours and then every two hours for the next four hours. Every four hours for the next 16 hours. Every eight hours for the next 48 hours. You see now why I popped it up on a box and didn't try to memorize that. Further documentation from the report I mentioned prior that will be linked in my description box. The fall happened on April 12th at 1130 p.m. and a neuro flow sheet was performed following the fall and continued until April 13th at 720 a.m. However, the patient was found to be unresponsive and have no observable signs of life somewhere between 7 a.m. and 715 a.m. at which time Nurse Ganey and the nursing aides and staff gathered the patient up, transferred the patient back to the room and put the patient in his bed. The patient was pronounced deceased approximately two minutes later at 717 a.m. However, according to the documentation done by Nurse Ganey, she had completed the patient's vitals and done a neuro evaluation at 720 a.m., which is three minutes after the patient was pronounced deceased. Nurse Ganey later admitted to phosphine documentation at 720 a.m. on that day. Review of the facility's camera footage showed that following the patient's transfer to the lobby at 1144 p.m. until 7 a.m., a period of over seven hours Miss Ganey did not complete any of the scheduled neurological checks. Furthermore, when the staff noticed that the patient was unresponsive, no attempt was made to call 911 and no resuscitative efforts were performed according to documentation and camera footage, which goes back to my previous point on knowing the patient's DNR status. However, per review of this facility's policies, review of the facility policy do not resuscitate in the event that the heart stops beating or breathing stops and there is no medical intervention started. Last approved, February 21st, 2018 revealed that all residents will be resuscitated, a.k.a. the use of CPR when there is no observable sign of life unless they have a do not resuscitate order. So like it says at the very bottom there, in a not so confusing way, CPR will be initiated on all residents without observable signs of life unless a DNR order is obtained. So let's get back to the case. While the patient was also in the lobby for those seven hours, the patient was not hooked up to a feeding tube, which caused the patient to miss approximately six hours of nutritional support. It was also found out that the patient was not assisted to the toilet during this time of being on night watch and was found to be heavily saturated in urine and feces. Following the patient's death, he was transferred to a medical examiner, which noted that blunt force trauma and subdural hematoma resulted in the patient's death. So now that we know about the case and what exactly happened, let's talk about some of the questions I have about the case. One, why was the patient allowed to fall five times or four times before the final incident? Thanks to some internet folks, apparently there was some legislation passed to residents in long-term care facilities giving them the right to fall, which means basically that healthcare facilities and their workers have duty to educate patients on preventing falls, but we cannot ethically restrain patients to prevent them from falling. So basically we can't morally put them in restraints or even have bedrails on the sides of the beds to prevent falling because it limits the patient's autonomy or their right to fall. And I'm hoping someone in the comments below that works in a long-term care facility can kind of help me out with this one because this was the first time I've ever heard of this piece of legislation. It kind of goes against what you think because if you had someone fall multiple times, you think you would at least put up bedrails or something to prevent them from falling again, but I don't know, I don't work in a long-term care facility, so this is definitely news to me. The other particular thing about this case is that you may say, well, if the patient fell four times already, why weren't they transferred out to the hospital or somewhere to monitor them closely? Well, it may come down to payment. So anytime a patient goes to one of these facilities, they're usually paid for by the Centers for Medicare or Medicaid Services. If for some reason, during the first 30 days of that admission at the long-term care facility, the patient has to go back to the hospital, the CMS does not reimburse the long-term care facility appropriately. And they may not even pay them at all because they may see that this facility is unfit to care for sick patients, they don't deserve their money. So what happens in this scenario is that long-term care facilities may actually hold onto these patients longer and longer, even though they may require a hospitalization because they don't wanna lose out on funding. And this doesn't just happen in long-term care facilities. It's also true with like dialysis work, which is in my wheelhouse. Sometimes a patient will come in with a fistula and we may need to do some work on it. And if that patient comes back within 30 days after having the initial treatment, we don't get paid for it because it was deemed that the procedure we did prior was unsuccessful for whatever reason. And that's just completely up to the CMS. The next question I have about this case is why was Nurse Ganey in charge of 39 patients by herself? Now that is a very good question that I unfortunately don't hold the answer to. Maybe the long-term care facility didn't wanna pay for three to four nurses because that's expensive. Or maybe they had a nursing shortage and couldn't get coverage for the night. And they just had to take whatever they could get. I don't think we'll ever know the reason for it because I doubt the administration will ever tell us and nobody's gonna go after them apparently so we'll never know. The next question I have is why did Nurse Ganey falsely document that she did neurological evaluation after the patient had already passed? Falsely documenting stuff in medicine is one of those huge no-nos that we are taught from day one not to do. Never document something that didn't happen for this reason and many other reasons. But with that being said, false documentation happens every single day in every single hospital. You think every healthcare worker that's taking vitals is counting respirations every single time they go and do vitals? No, I don't even know who does that. But it's always documented. As the nurses who are watching this know there are tons of things that they're supposed to document on a daily basis that it may not add any value to anything or anyone in respect to patient care. But they don't have time to document everything because they're already stretched too thin as it is. I'm not saying you should falsely document stuff or that all documentation is dumb. I just think that excess documentation is a systemic issue. And yes, you should never falsely document. The next question I have about this case is why did they bring the patient to the lobby or near the nurse's station after he had his final fall? Was it to keep an eye on the patient because they knew they had such a high patient census of 39 patients and they didn't think that they would be able to get to all the neurological checks over the next couple of hours? And maybe they thought that they could keep a close eye on him or were able to see them with their own eyes that would make up for not being able to do neurological checks. I don't know. The next question I have about this case is why were no resuscitative efforts performed? I think we know the first answer is the patient had no code status which is an issue from the very get-go. The goal of acquiring a code status is that the entire healthcare team is on the same page in the event of the patient's heart stops. It helps to alleviate questions and running around looking for patient information when a patient's heart stops because time is of the essence, obviously. So why didn't they get the code status? Who knows? However, given the fact that Ms. Ganey was a travel nurse that was just covering a night shift at this facility that she may or may not have ever worked in before, I doubt she was familiar with this particular facility's CPR guidelines on patients who do not have a code status. However, this facility's guidelines for that particular scenario are pretty common amongst every hospital I've ever worked at. So what about Cathedral Village? What did they do after this incident? Well, this particular long-term care facility posed immediate jeopardy to patient health and safety. And on April 19th, 2018, or six days after the event, an immediate action plan was developed, including the following. One, all staff will be reeducated immediately regarding the abuse, neglect, and exploitation with emphasis on definition, examples, and reporting requirements. Alternate staff on site will be educated immediately. Fall management program policies will be revised immediately. All residents will be reassessed for fall risk. Alternate facility staff will be reeducated regarding the policy modifications immediately. All new admissions will be assessed for fall risk within four hours of admission. So what was the result of this case? Well, Nurse Ganey was originally charged with felony neglect and involuntary manslaughter, which are quite the charges. However, she pleaded down and got sentenced to six months of house arrest with another four years of probation. She'll also be barred from seeking reinstatement of her license or working in a care facility during those four years. So the question we've all been waiting for, what do I think about this case? Well, for one, I think the fact that this happened is absolutely terrible. Nobody wants this to happen to their loved ones and nobody expects anything like this could happen to their loved ones when they go to a long-term care facility. My 94-year-old, Randad, is currently in a long-term care facility and I visit there frequently. So this definitely hits a little close to home. And now that I think about it, I only remember seeing like one to two nurses while I was there and they have a pretty sizable community, which now makes me question what the actual nurse-to-patient ratio is and I'm going to try to find that out. I don't think it's the nurses fault that they are putting these situations with high patient-to-nurse ratios. This is just another example of systemic issues within healthcare. Nursing shortages and hospitals and healthcare facilities not wanting to spend the extra money to pay nurses to ensure the safety of their patients. This is all too common. She was basically a substitute nurse who was left on her own to care for dozens and dozens of patients overnight and that pretty much hit the nail in the head. Like seriously though, how are you supposed to be doing multiple neuro checks an hour when you have a census of 39 patients? It's just not feasible. And speaking of this being a systemic issue, again, I asked, why are the administrators not held accountable or held to the same standard as the nurse? Is it because it's easier to blame one single person rather than an entire system that sets their employees up for failure? And like I spoke about in the Redonda Vaught video linked up here, this is just another hit to nurses and all healthcare workers. Our goal in healthcare is to promote a just culture which establishes unity and positively impacts work environments. A culture in which mistakes that happened are discussed and the causes of these errors are figured out together so that they don't happen again rather than just automatically punishing one person. If you only punish one person for their mistakes when more than one person was involved, the one punished is ultimately failed by the very system they work for. And it definitely doesn't help with bringing those mistakes forward. I do want to make it clear though that the mistakes misgain me made are unacceptable. However, there's always a however, the system needs to be changed as a whole and the system needs to be held accountable, not just one person. Otherwise we will continue to see healthcare shortages and decreased reporting of incidents which is ultimately worse for healthcare workers and ultimately their patients. Thank you all for watching everybody. If you enjoyed this, please leave a comment below. Let me know what you think on the case and as always, please subscribe to my channel. Follow me on Instagram and Tech Talk if you don't already and as always, I'll see you all on the next video. Bye.