A lawsuit was settled on July 20, 2021, against a New Hampshire nursing and rehabilitation center, after a 90 year-old woman died in February 2019 at the facility when her roommate turned off her oxygen. The lawsuit was filed by the victim’s daughter, who was the executor of the resident’s estate, against the nursing home and other entities.
According to the lawsuit, the 90-year-old resident was admitted to the New Hampshire nursing and rehabilitation facility on February 14, 2019, for rehabilitative care. She required a high-flow oxygen concentrator for her survival, but otherwise was stable, of sound mind, and in good spirits. She was placed in a room with another resident who had severe dementia and spoke only French.
On the night of her admission, the roommate turned off the oxygen concentrator because it was “too loud.” The medical examiner’s autopsy report stated that the victim died as a result of acute chronic respiratory failure due to severe oxygen-dependent pulmonary emphysema shortly after her supplemental oxygen was turned off by her roommate.
The New Hampshire Chief Medical Examiner determined that the manner of death was homicide. The New Hampshire Attorney General investigated the homicide and determined that the roommate was not competent.
Additionally, the lawsuit states that at the time of her death, the facility staff were unaware her oxygen concentrator had been turned off and only learned of the victim’s passing when her body was already cold to the touch. On the night shift of the victim’s death, the only licensed practical nurse on duty was absent from the facility for about 30 minutes at or around the time of the victim’s death. The defendants in this case denied these allegations.
The attorney who filed the lawsuit said the defendants were reasonable in coming to an “amicable resolution.”
Issue:
A resident who requires oxygen should be assessed routinely by nursing staff to ensure that the oxygen is flowing without obstruction at the ordered rate, and the resident’s oxygen level is within normal limits. The findings of the respiratory assessment should be well documented. Additionally, roommate selection should be discussed among facility leadership to ensure that all resident placements are compatible and safe and that the best accommodation has been made for each resident.
Discussion Points:
- Review your policy and procedures for the roommate selection process. Additionally, review your policies and procedures for respiratory assessment for those receiving supplemental oxygen. Update as necessary.
- Train all appropriate staff on your policies and procedures for roommate selection and respiratory assessment. Place each signed document in the employee’s individual education file.
- Periodically audit to ensure that residents with roommates are appropriately matched. Additionally, periodically audit to ensure that respiratory assessments are being completed by nurses with demonstrated competency, and that the respiratory assessments are documented per your policy and procedure.
