Gloria, the nurse for five or six patients on the orthopedic floor of a hospital on the east coast, didn’t seem quite prepared to get medicine into Helen, a 91-year-old who had trouble swallowing for a number of reasons, including the fact that she has severe Alzheimer’s and had recently been intubated (had a tube down her throat) for surgery.

Gloria walked into the room, mixing the crushed pills into applesauce.  She seemed to be in a big hurry.  She scooped up a heaping teaspoonful, about six times what anyone else who feeds Helen or gives her drugs puts on a spoon, and rapidly pushed it into Helen’s mouth.  I was reluctant to speak up; by then I knew that if I complained, Helen would suffer for it.

Helen was grimacing, moving the applesauce around in her mouth, but not swallowing.  Gloria pushed another heaping teaspoonful, the balance of the dose, into Helen’s mouth.  Immediately, Helen started spitting out all of the applesauce.  It spilled onto her chin, oxygen tube, chest, gown, etc.

Gloria looked at her and said, “What’s the matter? Applesauce too cold?”

She then scraped the spit out applesauce from Helen’s face, hospital gown, etc. and started trying to get it back into her mouth. She didn’t even clean Helen up afterwards.

Four hours later, when Helen was to get the next dose, Gloria walked into the room, pills in hand, and said, “You got any applesauce? And a spoon?”  I didn’t think it was my job to provide these items, but I went running down the hall to get them anyway, afraid that otherwise Gloria would go away for a long time, and Helen wouldn’t get the pain relief she needed.

Red flags in these situations include:  the nurse created the impression that she just didn’t have time for the patient; her technique was clearly unlikely to work (putting too much on a spoon); her approach in fact didn’t work; her fix was unsanitary, scraping food and medicine off the patient and putting it back into her mouth; after her actions created a mess, she ignored any sense of hygiene or dignity and didn’t clean the patient up (or arrange for anyone else to do so); and she expected family members to fetch materials she needed to do her job administering medicine.

Next week’s column will discuss when/how quickly these and other red flags justify asking for help from the nurse’s manager, often called the nurse supervisor or nursing supervisor, how to approach those conversations, what questions to be prepared to answer, and what is likely to happen next.  It also suggests steps to take in the unlikely event that the nursing supervisor doesn’t resolve the problem.