May 01, 2023

RN neglect leads to death: Alarms turned off, family FaceTimed during shift

RN neglect leads to death: Alarms turned off, family FaceTimed during shift

A Registered Nurse (RN) with 15 years of experience has had her registration cancelled after neglectful care, such as turning off heart monitor alarms and using her phone to FaceTime family during a shift contributed to the death of an 85-year-old patient.

As a result, the New South Wales Civil and Administrative Appeals Tribunal has cancelled Geraldine Lumbo Dizon’s nursing registration due to professional misconduct and she cannot seek reregistration for at least 12 months. 

“The period of suspension is imposed, not by way of punishment, but rather for the protection of the community,” the Tribunal said.

Ms Dizon, a Registered Nurse in Australia since 2006, has worked at the Nepean Public and Private Hospitals during her entire tenure. But on October 28, 2022, the Health Care Complaints Commission filed four complaints against Ms Dizon. 

The complaints centred around Patient A, an unnamed 85-year-old man admitted to Nepean Private Hospital with heart and renal failure on July 16, 2021. The man was placed on a heart monitor following an angiogram on July 27 and was expected to be discharged within a week, yet he was found deceased on the morning of July 30.

Ms Dizon worked a 10-hour overnight shift from July 29-30.

A timeline of events brought before the New South Wales Civil and Administrative Tribunal revealed Ms Dizon demonstrated a lack of critical thinking and a failure to provide safe care on several occasions, including inappropriate monitoring of vital signs.

“Patient A was an elderly man with serious comorbidities. RN Dizon’s decision not to attend observations as he may be discharged the following day does not demonstrate critical thinking,” the Tribunal found.

“For the reasons given, I find RN Dizon’s actions to be significantly below the acceptable standard.”

In addition, Ms Dizon disconnected telemetry alarm speakers that could have alerted staff to Patient A’s cardiac flatline as she wanted to keep another “confused patient safe” because they might get up to “answer my doorbell” if a previous alarm continued to sound. 

Ms Dizon failed to reconnect the alarm during shift handover and no one was alerted when Patient A’s heart monitor showed he was bradycardic (slow heartbeat) at 7:07AM and asystolic (cardiac flatline) at 7:14AM. 

Another medical professional was finally alerted to the situation at 7.20AM, with the man pronounced dead.

This critical lack of judgement was also paired with her failure to notify other staff of his irregular electrocardiogram (ECG) test and an improper patient handover. 

“In her letter of response (undated) to the Council she says that no one checked the patient during handover as they “were not thinking he would deteriorate as he was ready for discharge”,” the Tribunal said.

“Nurses have a duty of care to every patient in a ward and that duty of care does not cease because a patient is nearing discharge.”

Ms Dizon spent a total of 66 minutes on her phone during that same night shift, including a 12-minute period less than an hour before Patient A’s death.

“When questioned about this at her S150 hearing RN Dizon said that the 66 minutes were “not continuous” and that she uses her phone at work to “check on my family in the Philippines”,” the Tribunal said.

“Irrespective of whether her mobile phone use was continuous RN Dizon has clearly breached the hospital’s mobile phone policy.”

While the Tribunal also found that Ms Dizon was overworked – she worked 70 hours a week or more for consecutive weeks – it believed she had failed to act to reduce her fatigue due to those excessive shifts.

“Although RN Dizon denies she is fatigued, it is highly likely that working 70 hours of night shift per week has a detrimental impact on her health and performance.”

Ultimately, Ms Dizon expressed remorse for the events and the “lack of professionalism I demonstrated” and that she “decided to give up my registration”. The Tribunal found there was no evidence to support this. 

The Tribunal found her actions to constitute unsatisfactory professional conduct, and they believed there was no acceptance of responsibility. 

Ms Dizon can seek re-registration in 12 months but she will be required to undertake education courses to “demonstrate that she has a thorough knowledge of the standards required of a registered nurse”.

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