A physically disabled resident in a New York state-run care home required checks every two hours to ensure he was receiving adequate oxygen. On the night of September 10, 2013, his nurse fell asleep, and he went more than 8 hours without the checks. During this time, his oxygen level dropped to 40% (anything below 90% is considered dangerous), and he later died of hypoxic brain injury.
Says Patricia Gunning, prosecutor for the New York State (NYS) Justice Center for the Protection of People with Special Needs, “This case serves as a tragic reminder of the serious risk posed by an all too common workforce problem of caregiver fatigue or workers sleeping on shifts.”
Sadly, “all too common” turned out to be all too true. The NYS Justice Center for the Protection of People with Special Needs was formed in mid-2013, and oversees agencies responsible for more than a million people in state care or state-funded nonprofits. During its first year, it found 458 reports alleging abuse or neglect that cited a caregiver sleeping on the job. This included caregivers who slept through a resident’s grand-mal seizure and a resident’s elopement, residents with unattended access to medications and food, and residents who were in a car driven by a caregiver who fell asleep at the wheel.
Even with a seemingly overwhelming problem such as this, progress can be made by looking at the specifics of one case, identifying causes that led to the problem, and developing solutions. These solutions can then be considered for individual or widespread application. We will examine the specifics of this case in a Cause Map, or visual root cause analysis, which lays out the cause-and-effect relationships leading to a problem.
The problem being examined is determined by the impact to an organization’s goals. In this case, the resident safety goal was impacted because of the death of the resident. The resident services goal was impacted because the resident did not receive adequate oxygen. The compliance goal is impacted because of the felony charges against the nurse, who was sentenced to 90 days in prison.
Beginning with the most prominent impacted goal – in this case the resident safety goal – and asking “why” questions develop the cause-and-effect relationships that led to that impact. In this case, the resident died from hypoxic brain injury (per diagnosis), from a lack of oxygen. Due to the resident’s physical disability, his oxygen delivery equipment was required to be checked every 2 hours around the clock. On the night of September 10 to September 11, more than 8 hours passed between checks, at which point the patient was found unresponsive. (He died two weeks later.)
The resident’s oxygen delivery was not checked for more than 8 hours (as opposed to the required two) because the caregiver on duty had fallen asleep. Testimony from the nurse in question as well as others from the facility describing sleeping on overnight shifts as a common occurrence. Later research from the NYS Justice Center for the Protection of People with Special Needs found that many incidents involving caregiver sleeping on duty involved staff working extended or otherwise non-traditional work shifts. The nurse who fell asleep on duty worked 12-hour night shifts at a site where many signed up for overtime and just barely passed duty hour requirements.
In response to the numerous caregiver sleeping events it discovered, the NYS Justice Center for the Protection of People with Special Needs has provided a toolkit aimed to protect people with special needs from caregiver fatigue. The Center recommends that care provider agencies implement & regularly review policies meant to deter and detect sleeping on the job, establish contingency plans to relieve staff found unfit for duty, and provide assistance to residents in calling for help if caregiver is unresponsive. Due to the myriad issues associated with caregiver fatigue, the American Nurses Association (ANA) continues to fight to reduce nurse fatigue, and possible harm to patients.
To see a one-page PDF with an overview of the investigation related to the resident lack of oxygen due to caregiver sleeping, click on “Download PDF” above. Or, click here to learn more.