Mrs Daisy Mayes Case Study

Patient – Background Mrs Daisy Mayes, an 85 year-old woman was admitted with a chest infection and diagnosed with Bilateral lower lobe pneumonia. Whilst in hospital she sustained a fracture of the right neck of femur.
Medical History:
1. Hypertension. 2. Hypercholesterolaemia 3. COPD 4. Osteoarthritis 5. Bowel cancer (treated surgically 20 years ago)
Social situation:
Daisy is a widow of 5 years and has been living in a low care aged care facility since her husband’s death. She participates in the social activities within the aged care facility. Daisy has a supportive family (1 son and 1 daughter – her daughter lives locally and visits twice a week; her son lives interstate with his family). Members of her church parish also visit her once a week. She is a retired office worker. No longer drives – uses family and taxis to get around. Daisy is an ex-smoker who gave up smoking 10 years ago.

Daisy does not have an Advanced Care Plan in place, however her daughter Carol has medical power of attorney.
Reason for admission (10 days ago):
10 days ago at 0200 hours Daisy was brought in via ambulance to the Emergency Department (ED) following a period of high temperatures, shortness of breath and chest congestion. Her daughter, Carol, was notified of her hospitalisation and came into the ED to sit with her mother. A chest x-ray and blood tests conducted in the ED revealed that Daisy had pneumonia and she was commenced on intravenous (IV) antibiotics, HHFN oxygen therapy and Ventolin and Normal Saline nebulisers. Later that afternoon Daisy was transferred to the respiratory/medical ward. She was accommodated in a 4 bed ward quite a distance away from the nurses’ station.

Her daughter Carol stayed with Daisy throughout the shift. She asked the nursing staff whether her mother had been given any of her usual morning medications because Daisy could not remember having had them whilst in the ED. Staff checked the medication chart and found that Daisy’s usual medications had not been written up on her medication chart. Staff paged Daisy’s doctor to have her medications written up. Carol left for home at 9 pm. Before leaving Carol spoke with the nurse in charge of the shift and left her name and contact details. She asked to be contacted immediately if there were any changes to her mother’s condition. She told the staff that she was concerned that her mother was not ‘quite herself’. She seemed to be ‘a bit confused’. She also told staff that this was not a usual occurrence for her mother, as she was normally quite alert and orientated.

Overnight Daisy became quite distressed and more confused, calling out for her daughter and removing her oxygen. Nursing staff attended to her on one occasion and reapplied the oxygen prongs, re-orientated Daisy to the hospital and ward and then left to attend to other patients. At 2 am, a fellow patient in Daisy’s room rang the staff call bell and called out in a loud voice for help. The nurse allocated to Daisy answered the call and discovered Daisy laying on the floor next to her bed. Her IV was pulled out, blood was all over the floor. Daisy was moaning. A brief assessment revealed that Daisy had a laceration to her forehead and her right leg and foot looked like it was externally rotated. Daisy had also been incontinent of urine on the floor.

Daisy was reviewed by the resident medical officer, who ordered an urgent head CT scan and x-ray of Daisy’s legs. Results from the CT Scan was NAD, however the x-ray revealed that Daisy had sustained an intracapsular fracture of her right neck of femur. Daisy was scheduled for review by the orthopaedic team later that morning.

At 11 am, Daisy’s daughter Carol came in to visit her mother. She was very distressed to find that her mother had sustained a fall overnight and that she had a laceration to her forehead and had fractured her hip. She demanded to speak with the nurse in charge. She was angry that she had not been contacted and informed that her mother’s condition had changed and that she had sustained a fall. She said that she had told the staff that her mother was confused before she left for home last night and demanded to know why her advice regarding her mother’s confused state had not been listened to. She angrily stated that she wished to speak with the Patient Advocate officer as she was going to put in a formal complaint. The Nurse Unit Manager organised a meeting for Carol with the Patient Advocate. She also organised for Carol to meet with Daisy’s doctors to discuss Daisy’s progression of care.

Progression of Care
Daisy was reviewed by the orthopaedic team and it was decided to treat Daisy’s condition conservatively until her chest infection had improved. One week later Daisy had surgery for her fractured right neck of femur and a dynamic hip screw was inserted. Daisy was transferred to the orthopaedic ward post surgery. During her recovery, Daisy was reluctant to attempt to ambulate, and told staff that it ‘hurt too much to walk now’. 4 days post surgery, it was noted by the nursing staff that Daisy’s hip wound edges were not healing and there was a distinct odour coming from her wound. A swab of the wound revealed that Daisy’s wound had developed an infection. Questions:
1. Identify and discuss all the clinical practice issues of concern in Daisy’s care during her hospitalisation. Your discussion should include
a. examples from the case study
b. identify which standards have been breached
c. link how those practice issues demonstrate a breach to the National Health and Safety Standards (word limit for this section is approximately 500 words)
2. From the list of clinical practice issues that you have identified in Question 1 above, discuss
a. the 4 top priority issues that require attention in Daisy’s care
b. recommendations related to the priority issues you would make to staff/NUM for changes to health care practice generally at the ward level to ensure a similar situation does not happen with other patients. Provide rationales for your recommendations. Recommendations and rationales are to be supported by evidence-based literature.
(word limit for this section is approximately 500 words).