A 60-year-old man with a diagnosis of acute respiratory failure, chronic obstructive pulmonary disease (COPD) and known thoughts of suicide yanked out his own tracheostomy tube while a resident at the California Gardens Nursing and Rehab Center in Chicago, Illinois. The man was discovered by nursing home staff and transferred to a local hospital where he died the following day.
The shift supervisor was well aware of the resident’s repeated tendency to try to physically remove his breathing tube. The resident was wearing soft restraining mittens on both hands to prevent him from doing just that. However, for reasons that remain unclear, the supervisor did not indicate that risk on the resident’s initial plan of care even though he had assigned a staff member to be with the resident non-stop for the last four hours of his shift.
There was no self-harm assessment completed when the resident was first admitted to the facility. During his short stay in the facility he attempted to pull out his breathing tube numerous times, but no special monitoring was ever instituted.
It was inevitable that eventually the resident would succeed in removing his breathing tube unless action was taken, and he did.
Certainly, a person of sound mind has the right to refuse medical treatment. It is considered battery to treat a competent patient against his or her will. But, there was no documentation of this patient’s preferences for medical care, and his mental status would need to be assessed to rule out treatable depression or other factors impeding his judgment. In short, this patient may have had to take matters into his own hands, literally, because nobody took the time to listen to him or conduct the appropriate assessments of his mental status.
In Illinois, the law requires that nursing homes protect their residents from harm, even harm the residents are trying to do to themselves. If the nursing home had reported the man’s many attempts at suicide prior to the final attempt, a detailed investigation into his motivations could have saved him from such a grisly demise.
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