Resident death shines spotlight on shift changes

Think your staff documentation and shift change procedures are well honed? One Connecticut nursing home’s experience serves as a reminder that diligence must be practiced every hour of every day.

Despite the 95-degree day in late July, 79-year-old Sally Gerrity wanted to spend her afternoon sitting in the garden. Gerrity, a resident at Gardner Heights Health Care Center in Shelton, Connecticut, uses a wheelchair and needs staff assistance for mobility.

The facility staff wheeled her to the garden around 1 p.m., ensuring that she had sunscreen on and a cell phone nearby. An hour later, a staffer checked on her, offered her some water and reported that she was alert and comfortable. At 3 p.m., the staff shift change occurred.

Around 5 p.m., someone noticed that Gerrity wasn’t at dinner. She was found outside, unresponsive in her wheelchair. The city’s emergency medical services responded and recorded a body temperature of 105.7 degrees. They brought her inside, where she died about 40 minutes later. Gerrity had signed “do not resuscitate” and “do not intubate” orders, according to the Connecticut Post.

According to the Nursing Home Compare rating profile accessed today, the 130-bed facility had a five-star rating overall and the highest possible score for the quality measures category. The facility also received a respectable four out of five stars in the staffing category, with per diem hours with residents falling just under the national average for registered nurses, nursing assistants and licensed nurse practitioners.

The case reinforces the need for facilities to check residents according to protocols, create seamless shift-change procedures and record those actions through signed documentation and/or video, even those that take place outdoors.

Topics: Risk Management , Staffing