An 83-year-old female was transferred from hospital back to nursing home. Patient had open reduction internal fixation (

[answerhappygod]

An 83-year-old female was transferred from hospital back to
nursing home. Patient had open reduction internal fixation (ORIF)
of her hip. Prior to fall patient had been a resident of a nursing
home. Patient history includes congestive heart failure with
frequent exacerbations and arthritis. Patient’s vital signs: blood
pressure 137/76, heart rate 82, respiratory rate 18.
Medication transfer order from hospital included an order for
Lasix as well as other meds. Lasix was also part of nursing home
med before patient was transferred to hospital for hip fracture.
All the new med order from the providers transfer orders were
re-written on patients new MAR at the nursing home.
However, patients old MAR from previous stay had not been
removed. When the nurse at the nursing home checked the new orders,
she mistakenly misinterpreted the new Lasix order on the MAR as an
unintentional duplication in transcription and yellowed out the
line on the MAR. Also, during the MAR check, the nurse was
interrupted by a phone call and did not complete the process of
checking the new orders. She asked another nurse to complete the
process.
The second nurse completed the double check of orders and noted
the old MAR was still present. She removed the old MAR and let the
nurse know she had completed the task.
The nurse passing the meds noted the line for Lasix had been
yellowed out, which she interpreted the med had been discontinued.
She also happened to be the same nurse passing meds for the next 3
days. Having interpreted that the med was discontinued
earlier, she removed the Lasix from the med cart and returned it to
the pharmacy.
The patient’s weight on the 3rd day after returning
from the hospital had increased 3 pounds from her readmission
weight. The weight was recorded in her chart with an indication
that a call would be placed to her provider. No new orders were
recorded following that entry.
On the 4th day, patient was noted to have extreme
difficulty breathing. Patient’s vital signs: blood pressure
190/110, heart rate 120, respiratory rate 28, and bilateral +4
pitting edema.
Patient’s lungs were assessed and were noted to have diffuse
crackles throughout. The attending provider was called. Provider
ordered patient be transferred back to hospital for acute
exacerbation of her congestive heart failure. While waiting for the
ambulance, patient went into cardiac arrest and could not be
resuscitated.
What questions would you ask to better understand the
contributing factors and or root causes for this event, and would
your questions have changed the outcome in preventing patients’
death?