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These are our stories, the real life stories faced by CCA and our members.

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Jennie Zaur

Below is a chronological order of events as witnessed by Jennie Zaur's daughter Jennifer Dingman.

Prior to hospitalization: Mother seeing three doctors, primary, neurologist and orthopedic.
 (Point) Assumption that all three doctors communicated all the time about her care, not accurate.
Neurologist had her on predisone for back pain, orthopedic had her on muscle relaxers and pain pills, and primary had her on blood pressure medicine, potassium and gout medicine. Sugars rose from steroids, primary was aware of predisone for back pain as he wrote script once while neurologist on vacation. Routine visit to primary in September of 94 showed very high sugar, diabetes medicine prescribed. Soon after taking glucotral XL she began to deteriorate. Primary insisted that her health problems had nothing to do with medicine and were from diabetes. She began to turn yellow, bruise easily, showed petechiae, swollen ankles, swollen feet, bloating, and eyes always glassy, short of breath, trouble urinating, and other problems, all within three weeks after taking new medication. Pharmacist told mother that he felt it was the medicine making her ill, she mentioned it to primary who got angry and asked her if she wanted her pharmacist to be her doctor? (he also let the pharmacist know he was not happy about his interference. )
(Point: Pharmacist discouraged from helping with patient education on medications)

She said no, he then indicated that if she did not want to take the medicine to find a new doctor. She did so in November of 1994, he concurred with the first primary that it was not the medication making her ill, but abruptly took her off steroids, not weaning her at all. She got sicker, problems with urination worsened, new doctor prescribed antibiotics for UTI on phone, (without any tests or exam), three rounds to be exact.  She began to get short of breath and chest pain as well, on Christmas of 1994 she went to the ER, they sent her home with more antibiotics for the UTI and said her heart was ok. (They didn’t do any tests either that day). At times she would not take the medicine without telling family, she would go a day without it and a day with it, the days after she did not take it, she would begin urinate normally. When I learned she was not taking medication I got upset with her and told her she had to take it consistently. Five days of her consistently taking the medication, that she stopped urinating completely for 24 hours, that was Jan. 3, 1995. On the morning of January 4th, she had a pain in her left arm and a fever of 103.4 her back and legs ached and were very swollen as was her face, she had a gray shadow around her mouth as well, the whites of her eyes were very yellow and her tongue had a furry coating on it. We called primary who told us to take her to ER but would not allow us to call an ambulance as it was an HMO and he made those decisions. We had to carry her down the stairs in our home because her ankles were so swollen she could not walk, (she was staying with us), and pull the car onto the lawn up to the door to get her out. At the hospital, she was catherized in the ER, a great deal of fluid poured out, she also had a chest x-ray, which showed what appeared to be infiltrates in the lungs, so it was assumed she had pneumonia. ( Point: might have been congestive heart failure) Her doctor did not see her for five hours after her arrival at ER, by then she was breathing better and much fluid had left her body through the cath. She was admitted that night to telemetry for observation. She was also given medication for pneumonia. On January 5 she was doing much better, no fever, new x-ray showed lungs clear, the swelling in her ankles and feet was gone as well. Doctor had prescribed extra potassium for her as she was passing a great deal of fluid. She was doing well after the fluids were released, her features no longer looked distorted but she was still yellow. On the morning of January 6, the doctor discontinued the catheter, but did not reduce the amount of potassium she was getting nor did he order any urine output measurement. (Point: urine output measurement would have been a red flag)

He ordered an echogram and indicated she would be going home the next day if she continued to be doing as well as she was that morning. She never urinated again. As the day went on, she began to feel nauseous and ill, she developed pain in her left arm and shoulder, radiating down to her hand. She ate very little. She was given an IV dose of potassium as well as a liquid dose that she drank, after she drank it, she became more nauseated. By early evening she was doing very poorly, the night nurse indicated that there was question about possible cancer and that she was not going to be released on Saturday but moved to the cancer ward. The nurse also said that the doctor did not want to tell my mother of the possible cancer until he was sure. When the nurses took her blood pressure, it was very low, yet they did not repeat it for several hours.
(Point: the records indicate that there was a machine on her, but there was no BP machine hooked up. )

The only action taken by nurses was a pulse oz machine put on her fingers. She had nail polish on and I later found an error in primary doctor history and physical that stated that my mother was a smoker. history and physical state: “Smoker, I do not know how many packs per day” My mother never smoked a day in her life. The history and physical also said that my mother lived with her husband, which was also an error as my dad is dead and she lived alone.
(Point: Perhaps primary was confused as to which patient he was admitting when he wrote the history and physical). I later learned from several nurses who reviewed the records that the pulse oz readings would have been lower had a person her age been a smoker, what was presumed to be normal might have been a red flag had the history and physical been accurate on that account. ABGs would have helped determine what was going on.  Patients and families should always have the right to review the chart and medical records upon request)

As the night progressed, her condition worsened, she began to sit on the edge of the bed weaving back and forth and moaning, she never acted this way before. She was trying to make herself vomit, the nurses continually told me that there was nothing wrong with her and that I should go home, but she begged me to stay. She paced back and forth by her bed, she was trembling, it was very cold in the room as the heater was broken, the temp. Was 60 degrees; the staff said that they could not move her to another room even though there were plenty of rooms empty that night.(Staff told regulatory agencies that floor was full that night, it wasn’t)   She kept pleading with me to help her, she also said that she did not think she was going to make it if I did not help her, at one point she said to me, “do you want me to die?” This haunts me to this day and will forever. Three nurses and a respiratory therapist continually told me she was fine and it was apparent that I was getting on their nerves. I called a nurse in another part of the hospital that I knew and told her what had been going on, she told me to call the doctor at home and ask that a doctor examine her. The doctor was called at about 2:00 A.M. and called the nurses station about 4:00 A.M. He spoke to the charge nurse and then me. He seemed angry that I bothered him, told me that I was in the way of my mothers care, and that I should go home and let the nurses take care of her, as I was the reason she was so upset. He also said that there was “Nothing wrong with my mother that was not in her head”. And that he was not going to come in nor was he going to send another doctor up to examine her.
(Point: communications by staff to doctor not accurate)
(Point:  There should have been a patient advocate on call for me that night, no one told me if there was. I wish that I would have known that
Option existed, no one told me.)

My mother fell asleep about 5 am, so did I in the chair. She woke up at about 7 or 8 on the morning of the 7th of January. She had no memory of the night before, she seemed better. Instead she told me that she slept all right but she was awakened several times as she heard a woman crying for help. She did not know that I had been there all night either. There was no one crying for help there that night but my mother. The day nurse came and promised me she would take care of my mother and I should go home and get some rest. I was anemic at the time and also had a new baby at home. The nurse said that they would be moving my mother to the cancer unit that morning and that they would let me know her new room number. I left her that morning at 8:00 A.M. I fell asleep until about 11 A.M. at home, no one ever called. I called the hospital and was connected to a room but no one ever answered the phone. I called the nurses station and they assured me that my mother was fine and she would be calling me soon. She never called. By noon I called again, still no answer, at that time a nurse got on the phone and told me that my mother was not doing too well, she would not eat her lunch.
(Point: poor communication staff to patient’s daughter)

I soon sent my husband to the hospital with my two sons as I waited for my mother in law to stay with my baby. When I arrived, I went to the room that the operator told me my mother was in, there was another patient in that room who was non responsive, that is the phone number I had been calling all day. At the end of the hall I saw my husband and two nurses who looked upset. My husband said, “honey, your mother is not doing well and they called for the doctor”. When I got into the room she was behaving exactly as she did the night before. After being told all night by three nurses and the respiratory therapist that she was fine. The day nurses did not think she was “fine” at all. The lady in the next bed told me that my mother was doing well until the nurse gave her a small container of medicine to drink, the small potassium container was in the trash can next to her bed, yet not recorded in the records.   Shortly after that she began to feel ill and kept calling for me, yet no one contacted me nor did anyone indicate when I called the nurses station the first time that something was wrong. The day nurse told me that she had begun calling the doctor before 11:00 A.M. and he did not get back to them. He finally arrived after 2:00 P.M. When he saw her condition, he looked puzzled, he admitted that he did not know what was wrong with her. By this time I was very worried and in tears, he said to me, “what do you want me to do?” I responded with a question, aren’t there any other tests that could be taken? He then ordered ABGS. I asked him about the results of her echogram and he indicated that he had not seen them yet. (Yet the nurse the night before told me that her liver was enlarged on that echo and that was why they suspected cancer).   He went to the desk to look into that. My mother was looking worse by the minute; the technician came to take the ABGs and was looking for her veins when he indicated that he could not feel her pulse. There was an oncologist visiting the woman in the next bed, he immediately jumped in and began CPR and then my mom coded, they called the crash carts and kicked me out of the room. I was crying hysterically in the hall saying over and over, “why wouldn’t they listen to me?” The nurses were crying with me.
(Point the nurses got in trouble for that)

I was soon escorted to a room with a very nice nun who I proceeded to tell a full account of the events of the night before to. She also cried and told me I HAD to tell the hospital everything that happened so it never happened again. At this point I thought that I had lost my mother, but the primary came into the room and told me that they got her back but she was not breathing on her own and they were taking her to ICU. He the asked to meet me in the cafeteria. There he told me that he had no idea how sick she was and that the nurses did not tell him anything. He also told me that when he called them in the middle of the night they made it clear that they felt she was fine. He seemed open and honest at that point, I hugged him and thanked him for all he did to recessitate her. Several days later his attitude changed and he was not friendly at all, he seemed aloof and not willing to discuss anything with me.
(Point: I needed to have an open relationship with the primary at this point, instead he backed off due to fears which actually caused me to question the situation. This cycle seems common with most other stories I have dealt with)
My mother spent 7 weeks in the ICU unit, she got basically good care there, I got to know many wonderful nurses there who were very forthcoming about her condition and the consequences of her MI. They allowed me to stay with her as long as I wanted to and seemed to really care. It was because of these individuals that I believe that there is more good in our system then most other consumers have been exposed to. However, several nurses really risked all by being as close to me as they were told to keep their distance and not talk to me about her unfortunate event. It was because of them that I understood that the system is the problem and that blaming individuals in it does little good.
(Point: The nurses’ were true heroes in the sense of helping the healing begin as they defied policy and still befriended the patient’s family member, this behavior should be rewarded, not forbidden.)

During a meeting after her MI, it seemed that everyone there was blaming each other for what happened. I said to them, “it was no ones fault as much as it was everyone’s fault” I also told them that there are problems with their system and that system was the biggest fault of all, I told them that I wanted them to fix that system and make sure that no one else had to go through what my mother did. I made it clear that I wanted those who participated in her care learn from their mistakes so they will not be repeated. (Point. I was not well received for that statement at the time, little did I know at the time that the system was much larger then one hospital). The doctor blamed the nurses and hospital and the nurses blamed the doctor, etc. They totally missed my point. I also begged them to do all that they could to bring her back to me as I felt that had they done a better job in her care, she would not have had the MI, sadly, that was not possible. She died on February 24, 1995, and my life has been changed forever.              

The day after my mother fell into the coma, I went to see the charge nurse who told the doctor that my mother was fine.   I did not angrily go to her, but wanted her to learn from her mistake.  I told her she was wrong in how she dealt with my mother’s care and that I wanted her to know so she did not do it again.  She was not gracious nor accepting of my remarks, instead she was rude, nasty and denied that she did anything wrong.  She said she was a good nurse, and that whatever happened to my mom happened on the other floor and she and her nurses had nothing to do with it.  She then threatened to have me thrown out of the hospital, and had the unit clerk call security, even though I was finished talking with her and ready to return to ICU.    I waited for  the security guard to talk to him as I was crying and felt terribly misunderstood.    As he walked me down the hall, he told me that I needed to not ever go back to telemetry or see that nurse, as she could have me thrown out and I would not be able to see my mother.    I told him that I was not threatening, then, with tears in his eyes, he said, I know, but this happens all the time and trust me, you don’t want to be thrown out of here.  I followed his instructions never seeing that nurse again.   Two nurses who worked under her had disciplinary actions taken by the nursing board, sadly, she was not one of them.    Lastly, I cannot go without mention of the forth nurse.  She was the one in the cancer unit whose charting was sloppy.   The nursing board was more interested in her then any of the others, even the one who charted an overdose of potassium.   I refused to file a complaint against the cancer nurse, because she was so sorry, she cried with me, and she knew that she should have been more aggressive in getting the doctor to see my mom that Saturday morning.   I have since heard that on several occasions this nurse has spoken out and saved lives.   What good would a complaint with the nursing board have done?   Why do regulatory agencies want to punish those who have already suffered enough by their own conscience and allow those who err to believe that they are doing well in their work?  


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