Leonila Ashford

Hello. My mother, Leonila Ashford, passed away on June 28, 2014. Her story begins back in May 2014. My mother had been complaining of her lower to mid back (on the left side) hurting. My mother was on kidney dialysis, so when I asked her to show me where the pain was, she told me right above her waistline. By looking at where she was pointing, I thought that maybe she had a kidney infection or that something was going on with her kidney. I asked her nephrologist and the kidney dialysis center about her vitals and I was told she was fine.

About a month later, my mother told me her urine was bloody. I took her to the ER, where they ran blood work and blood cultures and a CT scan of her pelvis and abdomen area. The doctors came in and said that she did not have a kidney infection or kidney stones or anything like that, but the cultures that did come back at that time revealed she had a UTI. (Sepsis and Urinary Tract Infections) She was prescribed Cipro. However, due to my mom’s heart health (enlarged heart and the starting on CHF – congestive heart failure) the doctor put her on Cephalexin for 10 days.

My mom completed the antibiotic and then she started to complain of pain in her side so she insisted on going back to the ER. I took her in and they ran blood work, cultures and CT scan of her side and found she had two broken ribs, BUT she also STILL had the UTI. We were released with another round of Cephalexin for another 10 days and told that sometimes it takes 2 rounds to kill an infection.

Well, four days later, my mom fell and she broke her hip, so they admitted her to the hospital because she could not walk. She stayed in the hospital for 6 days. She was admitted on Tuesday evening, 05/27/2014. On Thursday, 05/29/2014 she had a low-grade fever and the nurse asked why she was running a temperature. I told the nurse that she had a UTI and was given antibiotic, did one round and was on her second round and was on her fourth day of antibiotic when she fell. I thought the hospital was giving her the antibiotic since this was the same hospital that just saw her and all her records/info was in the computer.

The nurse went back to the doctor to tell the doctor what I said about the UTI and apparently, because they had done blood work and cultures, they looked up the results and they were normal so they figured that the temperature might be from her not being mobile. They said she needed to do breathing exercises. On Monday 06/02/2014, she was released to a nursing/rehabilitation center for her hip. The nursing center they sent her to I could not stand (long story) but I had her moved from that nursing home to a rehabilitation facility close to our home that she had been to before.

On Tuesday 06/03/2014, my mom was switched to the rehabilitation facility and we felt comfortable. On Friday, 06/06/2014, she started to develop high fevers. She called me and asked me to come as soon as I could after work. When I got there she was all covered up and she had the room heater on and set on 90 degrees. She was shivering and had chills. I started to get worried.

The nurse said that dialysis patients tend to get cold but my mother did not have dialysis that day. Her dialysis days were Tues., Thurs. and Saturdays. This was a Friday. She was running temperatures of 100.2, 100.7, 100.8 and then 101.2 all through that night. They told her to take the covers off. They gave her ice chips and gave her Motrin. The nurse also put wet washcloths under her armpits and on her forehead, but her temperature was still high. After the Motrin, her temperature started to come down. I felt as if the nurses thought she was okay but I knew my mom and I knew something was not right.

When the 11:00 pm shift nurse arrived I told him that something needed to be done because I felt she was fighting something. He called the doctor. The nurse came back in and said that they needed a urine sample but being that my mom was on kidney dialysis, she did not produce a lot of urine. I asked how much urine would they need. I was told that they would NOT need a lot. I told him they may need to do a clean catch with a catheter if they could not a get enough urine and I did not think getting a urine sample from the bedpan was a good idea. I never heard anything further about anything. I did ask everyday how my mom’s temperature was. I wanted to make sure she was not running low-grade fevers or running temperatures, and only being treated with Motrin.

I don’t know exactly when or how they got the urine sample, but they did and were able to get blood samples as well because on Friday 06/13/2014 at 4:30 pm, the nurse called me at work and said that some of my mom’s blood work and cultures came back and they tested positive for “blood infection.” I said to the nurse, “A blood infection? Shouldn’t she be hospitalized? I mean this is sepsis. I know about sepsis. Sepsis is a blood infection and you are telling me she has a blood infection.” The nurse responded, “Well, it is a blood infection and no we are not going to send her to the hospital. We are going to start antibiotics here. That is why I am calling you. We need you to come and sign the permission paper to have a PICC line put in so we can start the IV antibiotic.” I told her that my brother was closer and could get there before I could.”

I called my brother and he arrived at 5:00 pm and I arrived at 6:15 pm. When I arrived the PICC line was in and ready for her IV antibiotic. Here is where I really get upset. [Side note: This is a rehab facility. They were not equipped to treat sepsis. When I say they did blood work, what I mean is they had to call in a phlebotomist from a lab to come to the facility to take the blood. I never understood why the nurses there at the facility were not able or allowed to draw blood.]

At 6:15, when I arrived, my mom was ready to receive the antibiotic. I asked the nurse when she would be getting the antibiotic. I was told that they had to order it from the pharmacy. I asked why they did not have it in stock. Again, knowing this kind of stuff, why was she not admitted to the hospital? Well, 8:00 pm rolls around, then 9:00 then 10:00, by 11:30 pm I began getting beyond upset at the staff and asking why the delay in getting the antibiotic. I started to tell them that my mom had dialysis in the morning and at some point beginning the antibiotic would be mute since it would be dialyzed out but her treatment of the infection was being delayed. I was UPSET. I asked if I could go pick up the medication. The nurses kept saying they would call the pharmacy and check on ETA; that is all they kept saying. It kept getting later and later. By 12:30 am, the drive delivered the pump and the Vancomyocin. The nurses came in and felt very relieved and excited to tell me that it arrived. HA!

They came in at 1:00 am to tell me that the pump was DEFECTIVE and they needed the pump for the Vancomyacin. At this point I did not know what to do! I was so fuming mad! I cried! The nurses were afraid of coming to talk to me. One nurse finally came in and said, “Ms. Ashford, we have called the pharmacy and told them what is going on and about the defective pump and that your mom is having dialysis in the morning. He is going to send out a new pump (STAT) in the morning while your mom is at dialysis so by the time she gets back, we will be ready to give her the antibiotic.” All I could do was listen to her, acknowledge her and make notes.

On Saturday, June 14, 2014, my mother went to her dialysis treatment at her usual time. The transport company arrived at the facility between 10:15 – 10:30 and my mom’s chair time at the dialysis center was at 11:00. Her run time was for 3 hours, so that would put her completing her dialysis at 2:00 to 2:30 at the latest. Due to being at the mercy of the transport company’s schedule plus traffic, my mom would not arrive back at the rehab center until 4:30 or 5:00 in the afternoon. So on Saturday, 06/14/2014, I did not anticipate her being back until 5:00. I took care of errands and other things and took a shower and arrived at the facility at 7:00 pm.

When I walked into my mom’s room, she was fast sleep. The room was clean, no visitors, quiet, peaceful. I walked in quietly. I noticed that there was not a pump or anything in the room but my mom had already been back from dialysis a couple of hours so I figured they gave her the antibiotic. It was about 8:00 pm when the night nurse walked in looking for a tree pole. I figured since she was looking for a tree pole in my mom’s room that meant it must have been in there earlier so I asked her, “What time did my mom end up getting her antibiotic?” The nurse replied, “She has not received it yet.” I yelled “WHAT???!!!!!” Are you kidding me?????!!!!!!”

The nurse said, when the pharmacy sent the new pump, they failed to send a new bag of the antibiotic. “We had to wait for them to send another bag.” This put me over the edge. I asked the nurse, “When is the antibiotic supposed to get here? We are now going on 27 and half hours after the PICC line was put in to start medication. This is 27.5 hours AFTER finding out she has a blood infection. This is uncalled for!” I went on to say, “If something happens to her, we are going to have issues.” The nurse responded, “I understand. I will let you know as soon as it arrives.” I sat there with my mom and cried and I apologized to her that I felt like I was failing her. My mom kept telling me to give it to the Lord and let HIM handle it. She told me that she trusted HIM. My mom had a way of helping me turn to my faith; nevertheless, how they were handling this whole thing was uncalled for!

Well, 10:30 rolled around and the nurse came in with the tree pole, the pump and the medication. She got my mom all set up and started the IV antibiotic. I sat with my mom and talked to her, watched her to look for any signs of adverse side effects. She completed the dose at about midnight. I spent the night then my brother came in the morning and stayed with her on Sunday. I asked him to ask the nurses to check her temperature. Her temperature was normal all day Sunday. I asked the nurse Sunday evening when her next dose of antibiotic would be and I was told that she would be receiving only one dose of Vacomycyn. I asked why and was told that because Vancomycyn is a strong antibiotic and it is a broad spectrum antibiotic and it was used to just start treating my mom while they waited for the rest of her cultures to return so they could figure out what antibiotic to give her. They said it would be another day or two before they received the cultures back.

On Monday 06/15/2014, my brother and I came to see my mom around dinner time. The nurse came in and checked her blood sugar. When she did, I noticed my mom still had her PICC line in. My brother and I decided to get dinner real quick. When my brother and I returned from dinner, the nurse asked me if I noticed anything. I looked and she said, “Her PICC line is gone.” I said, “When was that removed? “ The nurse responded, “I took it out when you and your brother went to dinner.” I asked, “Why? How are they going to get blood to test to see if the antibiotic is working? How are they going to monitor her?” I kept asking questions and the nurse said, “I understand completely. I don’t know why they ordered the PICC line to be removed. I was thinking the same thing.” This was coming from the nurse! I wanted answers. I was told that she responded well to the Vancomycin. On Tuesday, 06/17/2014 I asked about the cultures and about the antibiotic, and was told that the PA ordered her to be on a 5-day oral antibiotic, Augmentin. When the nurse told me this, I was a little uneasy. An oral antibiotic after only one dose of an IV antibiotic that took over 27.5 hours to get into her system, after revelation that she had a blood infection? Really? I asked the nurse what was up with that? She said,” Your mom does not show signs of sepsis. We have been monitoring her symptoms. I was floored.

I made sure they gave her the oral antibiotic. I kept asking about her vitals and temperature. I was told she was fine. I asked my mom how she was feeling. She responded that her legs were hurting and that her lower back was still hurting. The staff never felt that her pain in her legs or the fistula in her arm that was hurting or the pain in her lower back needed to be addressed. They just gave her pain medication. Nothing was ever said to me or my brother after she completed her antibiotic. We were told they would monitor her (symptoms). On Saturday 06/28/2014, she went to her dialysis treatment but unlike the other days, the transport company got her back to the rehab facility at 2:10, what would have been her normal time but never was. It was now considered her being back early. She greeted the nurses like she always does with her cheerful, full of life spirit and then asked for her pain pill. The nurse brought her the pain pill, she watched my mom take the pill, the nurse walked out of the room and then my mom coded in the bed at 2:14. They called for rescue. My mom was a full code. When it was all said and done, my mom was gone at 2:24 but they had to work on her because of being full code. They called her death at 3:01 pm. My brother and I were contacted at 2:34 and told that she was not doing well. We arrived at the rehab facility at 2:35 and waited for explanations, answers!

When it was all said and done, my brother and I did not decide on an autopsy because of my mother’s health issues as well as cost. It was not going to bring her back but according to the nurses and everyone there and the response team, the pain pill they gave her did not have time to get into her system to do anything. We thought possibly she had a clot that went to the heart, lung or brain. We knew she was not as mobile as we wanted her to be so we thought that was a possibility.

We went on and made funeral plans and then had her cremated ONLY to then pick up the death certificate and written on the death certificate was “Septic Shock.” This then brought me back to the UTI and the non-aggressive way they treated her! I was beside myself and now feel so responsible and feel like I should have been insistent to make them admit her to the hospital especially when the pharmacy took nearly 30 hours before the first treatment then to only be treated with a 5-day oral antibiotic! OMG! I know that people can get sepsis from the hospital and they do die in ICU but my brother and I feel that even if they had admitted my mother to the hospital and she still passed away, at least we know she was getting the antibiotic quicker than 30 hours, she would have been monitored on a heart monitor, she would have been receiving fluids and then having dialysis to remove the excess fluid being she had kidney issues. The rehab facility was NOT equipped to handle sepsis or even if they felt like they caught the infection early and she was not septic, they did not monitor her to see or make sure she did not go septic. The nurses kept saying she was alert, her BP was normal, which is not true because one nurse took her BP while I was in the room and it was low. The rehab did not take vitals every hour or even every 4 hours. They took it during the day and ONLY if and when I requested. Looking back I believe it started as a UTI and once she tested positive for a blood infection she should have been in the ICU, because she was 72 years old, a kidney dialysis patient, sugar diabetes, cirrhosis of the liver and with a blood infection. This should have been treated at the hospital.

After reading about sepsis, I have decided to become an advocate and tell my mom’s story about being persistent with your healthcare providers. Ask questions. If not satisfied with the answers, ask and ask and ask until you get the answers. Be mindful and watch!!!!!! Nurses, CNAs, doctors are human and are fallible too! Don’t feel intimidated or stupid for asking. I did not care what the nurses thought about my anger or that I was a bitch but they were caring for my mother, my best friend, who is now no longer with us!

Source: by Christine Ashford (Leonila's daughter)