SCENARIO

Mr. J is a 72-year-old retired rabbi with a diagnosis of mild dementia. He was admitted for
treatment of a fractured right hip after falling in his home. He has received pain medication and
is drowsy, but he answers simple questions appropriately.

A week after Mr. J was admitted to the hospital, his daughter, who lives eight hours away, came
to visit. She found him restrained in bed. While Mr. J was slightly sleepy, he recognized his
daughter and was able to ask her to remove the restraints so he could be helped to the bathroom.
His daughter went to get a certified nursing assistant (CNA) to remove the restraints and help her
father to the bathroom. When the CNA was in the process of helping Mr. J sit up in bed, his
daughter noticed a red, depressed area over Mr. J’s lower spine, similar to a severe sunburn. She
reported the incident to the CNA who replied, “Oh, that is not anything to worry about. It will go
away as soon as he gets up.” The CNA helped Mr. J to the bathroom and then returned him to
bed where she had him lie on his back so she could reapply the restraints.

The diet order for Mr. J was “regular, kosher, chopped meat.” The day after his daughter arrived,
Mr. J was alone in his room when his meal tray was delivered. The nurse entered the room 30
minutes later and observed that Mr. J had eaten approximately 75% of the meal. The meal served
was labeled, “regular, chopped meat.” The tray contained the remains of a chopped pork cutlet.

The nurse notified the supervisor, who said, “Just keep it quiet. It will be okay.” The nursing
supervisor then notified the kitchen supervisor of the error. The kitchen supervisor told the staff
on duty what had happened.

When the patient’s daughter visited later that night, she was not told of the incident.

The next night, the daughter was present at suppertime when the tray was delivered by a dietary
worker. The worker said to the patient’s daughter, “I’m so sorry about the pork cutlet last night.”
The daughter asked what had happened and was told that there had been “a mix up in the order.”
The daughter then asked the nurse about the incident. The nurse, while confirming the incident,
told the daughter, “Half a pork cutlet never killed anyone.”

The daughter then called the physician, who called the hospital administrator. The physician,
who is also Jewish, told the administrator that he has had several complaints over the past six
months from his hospitalized Jewish patients who felt that their dietary requests were not taken
seriously by the hospital employees.

The hospital is a 65-bed rural hospital in a town of few Jewish residents. The town’s few Jewish
members usually receive care from a Jewish hospital 20 miles away in a larger city.

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 REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the
submission and no more than a 10% match to any one individual source can be directly quoted
or closely paraphrased from sources, even if cited correctly. An originality report is provided
when you submit your task that can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed
criteria that will be used to evaluate your work. Each requirement below may be evaluated by
more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions
of the course.

Analyze the scenario (suggested length of 2–3 pages) by doing the following:

A. Discuss how the application of nursing-quality indicators could assist the nurses in this case
in identifying issues that may interfere with patient care.

When reading this scenario, there are several ways that the application of Nursing-Quality
Indicators would have shown numerous issues that are affecting patient care and could have
possibly prevented some of the small errors that had already occurred during this patient’s
care. By using nursing-quality indicators, policies could have been in place to help with how
long restraints can be left on, how often they are released, who they can be released by, and
the reasons restraints can be put on. By looking at the indicators it could also have helped
this facility look at their staffing ratios and possibly add staff that can provide the type of care
that is needed to help prevent the use of restraints on patients just because someone cannot
watch or sit with the patient. With both of these nursing-quality indicators, staff ratios and
restraints, Mr. J would have been able to sit up, turn himself, and have someone watching
him. He would not have needed restraints and the ability to move would have prevented the
start of a pressure ulcer. When looking at the dietary requests/restrictions that Mr. J has, by
not following these or not caring that a mistake has been made can make the patient and his
family feel like his wishes are not cared about, when it could really be the lack of education
of the nursing staff. By looking at the nursing-quality indicator of nursing education,
education could be offered on different types of dietary requirements, types of foods to give
and not give, and an increase in dietary needs for patients while in the hospital.

B. Analyze how hospital data of specific nursing-quality indicators (such as incidence of

pressure ulcers and prevalence of restraints) could advance quality patient care throughout
the hospital.

When hospitals look at data collected that is specific to the nursing-quality indicators, they
are looking for ways to better improve patient care, the facilities policies and procedures, and
patient satisfaction. If the hospital looked at the data for the use of patient restraints and why
they were being used, it may show the hospital that they are being used in place of staff who
can sit with the patients or that there is a need for other devices, such as bed alarms, meaning
restraints wouldn’t be needed. When looking at the hospital data they can also see how many
patients who ended up with pressure ulcers had restraints used on them or if there were low

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 staffing numbers which prevented the patients from being turned or even out of bed that day.
By looking at this type of data it could help the hospital see if these issues are isolated to one
specific floor or if these situations are occurring hospital wide. The data could get more
nursing assistants on this floor and throughout the hospital, a standard policy on how long
restraints can be used at a time, and how often patients need the restraints released and turned
to prevent skin breakdown and even depression in patients. By lowering the number of
pressure ulcers and skin breakdown, it could lower the length of stay for patients, lower costs
for supplies, and improve patient satisfaction scores, making this a hospital that more people
would want to go to.

C. Analyze the specific system resources, referrals, or colleagues that you, as the nursing shift
supervisor, could use to resolve an ethical issue in this scenario.

Putting myself in the role of the nursing shift supervisor there are several resources that I
would use to help educate and resolve the ethical issue that occurred in this scenario. One
thing that I would have done first and foremost would have been to notify Mr. J’s daughter.
If I were her, I would want to know firsthand instead of finding out later and feeling like the
staff really didn’t care. The next person I would go to in this situation would be Mr. J’s
physician, who is also Jewish, to see what we can do to help the nurses, kitchen staff, and
other hospital staff/departments better understand the Jewish religion and the care that is
needed while in the hospital. By going to the physician, he may be able to explain why a
Kosher diet is so important to the Jewish community, what the diet consists of, and why
certain orders are used for the Jewish community in the town. I would also contact the
hospitals clergy staff to possibly talk to the patient and his daughter. Hopefully by having
either the Rabbi or multi-denominational clergy speak with the patient we could better
understand what we as staff need to be educated on in how to care for members of our
community and their religions. I would also put in a referral for the hospital’s dietician to
make sure that the dietary needs and requests of the patient are met. I would also personally
meet with the dietician to see if she could have a mandatory education session for the rest of
the floor staff. By having this education session, it will better educate the rest of the staff
recognize mistakes that occur with dietary trays of the patients and the errors can be fixed. It
is a learning opportunity for the entire floor and hospital. The last thing I would do as the
nursing shift supervisor would be to hold a debriefing session or a staff meeting to make the
rest of the staff on our floor aware of the things occurring on the floor and how do we feel as
a unit that we can fix these things. By holding the informational sessions, staff meetings, and
debriefings it opens up another nursing-quality indicator of RN survey and satisfaction. By
having the nursing staff input in the situations occurring on the floor it makes them feel like a
part of the solution on how to fix the problem. The nursing staff on the floor are the ones on
the front line and taking care of the patients every day. They are the ones who build
relationships with the patients and may know more than the higher ups in the facility. They
can add valuable input and suggestions on how to end the ethical issue in this scenario and
others that may be occurring on the floor or in the hospital. By working together, we may be
able to provide the care that is needed to the Jewish community so they don’t have to drive so
far away for the care that they deserve.

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 D. Acknowledge sources, using in-text citations and references, for content that is quoted,
paraphrased, or summarized.

NDNQI Indicators. (n.d.). Retrieved October 22, 2019, from

https://nursingandndnqi.weebly.com/ndnqi-indicators.html.

The National Database of Nursing Quality Indicators® (NDNQI®). (n.d.). Retrieved October 22,
2019, from
http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJI
N/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.html.

What Are Nursing Quality Indicators? (2019, September 25). Retrieved October 22, 2019, from
https://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-
indicators-anyway/.

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