I’m sure you have all had to care for “problem” patients during your nursing practice. Sometimes you are tempted to ignore their requests or wait until the last minute to enter their room to provide care. Added to the existence of a problem patient, you may be experiencing issues in your personal life that make caring for the “problem” patient even more frustrating.

The following case study is one that highlights these two issues and how one “problem” patient’s care arguably caused his death.

Mary Clark is a 45 year old registered nurse with a bachelor’s degree and a certification in geriatric nursing. She has been practicing nursing for the past 22 years. For the past 10 years, she has worked at Delta Nursing Home and Rehabilitation Center in her home town. She has an excellent reputation for providing quality care to her patients and was recently awarded a Nursing Excellence Award in Geriatric Nursing from the state nurses association.

Despite Mary’s success in her professional life, her personal life has not fared as well. She recently went through a messy divorce and her ex-husband fought bitterly for the custody of their two children, Megan, 8 and Todd, 6. The court awarded the couple joint custody. This has translated into the children living with Mary during the week, then going to their father’s house, several miles away from Mary’s, for the weekend. The ex-husband takes the children to their respective schools on Monday morning.

Mary has found that she is increasingly stressed by the child custody arrangement. Megan is not fond of leaving her father’s home every Monday morning to return to her mother’s home after school. Todd, in contrast, is happy to be with his mother and does not like staying with his father for more than one night. Mary does not know how to resolve this situation short of petitioning the court for a change in the custody arrangement.

She has also thought about moving to another city so that the every weekend custody arrangement would not work out. She is certain she could get a job most anywhere with her experience and awards. All these options, though, would cost additional money for lawyers’ fees, require her to have additional stressful contact with her ex-husband, and has created a concern over additional therapist visits the children may need to work through their latest objections to the joint custody arrangement.

Mary has decided to work as much as she can on the weekends to try to earn additional money in the event she decides to petition the court for the changes she is contemplating. As a result, she currently works two 8 hour shifts, or 16 hours, each Saturday and Sunday, then returns to her full-time weekly schedule during the week. Mary has noticed that she is becoming increasingly fatigued meeting this schedule, and is not sleeping as well since she decided to take the extra work. She also noticed that some of the residents “bother her” more than they have in the past. But, she rationalizes, the income from the weekend shifts really helps save for the possible court challenge.

On the evening shift (3:00 pm-11:00 pm)( her second shift on that day), she was assigned to care for Richard Romero, an 82 year-old male resident of the nursing home. He shared a room with George Johnson, an 80 year-old male resident who had been at the home for 12 years.

Mr. Romero’s diagnosis was cardiac insufficiency with moderate to severe mental impairment. He has limited mobility. He stayed in bed most of the time but could get up with help from staff.

Mr. Romero has no immediate relatives. A niece visits him once a year around the Christmas Holidays. The niece is the designated agent for Mr. Romero’s health care and finances, and Mr. Romero did tell one of the nurses that she stands to inherit whatever he has upon his death. The niece has not been actively involved in his care decisions. Rarely has an issue come up that she has had to be contacted in order to obtain directions about her uncle’s care.

Mr. Romero is a “good” resident most of the time, but occasionally he refuses to take his heart and other medications. When he does so, he can be quite adamant about the refusal. He has been known to ring the nurse’s call button continuously for attention, and when the nurse does enter his room, he feigns loosing consciousness, and if the side rails are not up on the bed, slides to the floor carefully ( but never hurting himself) so that several members of the nursing staff have to help him back into bed. He has a reputation for loving the attention he gets from this behavior.

It was about 4:30 p. m. when Mary heard what she thought was Mr. Romero’s call bell ring. She became irritated, knowing that he was probably just trying to get attention from the nursing staff again. Besides, she had several other residents to care for who were really ill and needed her immediate attention. She decided to ignore the call bell, thinking that he could just wait for awhile. During change of shift report his nurse said he had had a good day and he looked fine when she had seen him just before the end of the day shift.

The call bell continued to ring for the next 45 minutes. Mary was quite irritated now and went to Mr. Romero’s room. Upon entering the room, she saw Mr. Romero lying on his left side of the bed with his head between two of the side rails. Mary immediately pushed the emergency button in the room, and went to Mr. Romero to see if he was conscious. He was not conscious, his face was blue in color, and was not breathing. When other nursing staff came into the room, they were able to remove Mr. Romero’s head from between the two bed rails, and began initiating CPR after no pulse or heart beat could be detected. Paramedics were called. Mr. Romero was pronounced dead by the paramedic after resuscitation efforts failed.

Mr. Romero’s roommate, Mr. Johnson, kept shouting, “I used the nurse call bell for 45 minutes when I saw him get stuck in those bed rails but no one came. No one! I tried to tell him not to try and get up and to wait for someone, but he said “No one cares if I ring that bell. I’m going to get up myself.”

If Mr. Romero’s niece files suit against the nursing home and Mary, what result would you predict? Why? What could have been done by Mary to avoid this tragic event? Or, was Mr. Romero’s death his own doing?

How do you think the jury will evaluate Mary’s personal stress and its effect, if any, on her care for Mr. Romero? Who might be subpoenaed to testify about Mary’s stress and its effect on her nursing care of all of her patients, including Mr. Romero?

What will Mary say in her testimony about the incident? Will her husband be called to testify about their dispute during their divorce and the child custody arrangement?


Comments about the case study, and possible answers to these, and other, questions will be the subject of the next Bulletin.


Nancy Brent

Nancy Brent

Nancy J. Brent, RN, MS, JD, a nurse attorney in private law practice in Wilmette, IL, represents nurses and other health care providers before the state agency that regulates health professionals. Brent graduated from Loyola University of Chicago School of Law in 1981. Her experience prior to opening her private practice included a year of insurance defense for a major insurance company and establishing a law firm with two other attorneys. After three years of doing defense work at the firm, Brent decided to establish a private practice in 1986. Brent has published extensively and has lectured across the country in the area of law and nursing practice. She is a member of several legal and nursing professional associations, including the American Nurses Association, Sigma Theta Tau International Honor Society of Nursing, the Illinois State Bar Association, and The American Association of Nurse Attorneys (TAANA).

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