Nurse Case Manager Chronicles

The Fragility of Life

When routine surgery went awry and upended a workers' life, her nurse case manager guided her through physical and emotional recovery.
By: | February 1, 2018 • 7 min read

In the blink of an eye, a routine case can turn into a catastrophic claim. And when it happens, nurse case managers lead the push to help the patient recover — physically and emotionally.

A worker — a registered nurse — tore her rotator cuff while moving a patient. It’s a common injury among nurses, and she filed for workers’ compensation. Before surgery, she met with her nurse case manager to review the case and the therapy she would need afterwards.

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But her routine surgery became her worst nightmare when she coded on the operating table.

“She coded a couple of times,” said Becky Mills, a nurse and certified case manager with Ascential Care Partners, headquartered in Lexington, Ky.

In medical terms, this means the patient went into cardiorespiratory arrest, which required CPR to bring her back. After surgery, the patient was placed in critical care on ventilators.

During surgery, the patient’s blood pressure skyrocketed, Mills explained. Medications were administered to lower the spike, but instead of stabilizing the patient, the medications led to her coding. She suffered a stroke.

Mills said it wasn’t clear whether coding led to the stroke or if the stroke led to coding. Either way, the patient fought for her life.

“It was a dim prognosis; there were times I didn’t know if I’d see her out of that hospital,” she said.

But, said Mills, she had an amazing support system and pulled through.

From Crisis to Care

Mills didn’t know what had happened at first.

“I called the day after surgery to check in,” she said. Mills believed her patient was still recovering from a routine rotator cuff repair. When no one answered the phone, she left a message and brushed it off. “It was the day after surgery. Sometimes people are still groggy.”

When she called the next day and received no answer, she knew something was up. The patient’s husband called to tell Mills about the stroke.

“The employer didn’t even know,” she added. The NCM had to inform them of their employee’s condition.

Becky Mills, RN, certified case manager, Ascential Care Partners

Mills met with the patient’s husband in the ICU, determined to get medical records in order and help ease his worry.

“For a while, it was maintaining contact and communicating with the employer,” she said. The employer was investigating the incident, deciding whether or not the stroke and subsequent care would be considered under the workers’ compensation claim already in place.

During this time of uncertainty, the husband told Mills it was nice to have a neutral body there, someone who could handle the work-related needs while coordinating care options for his wife. He told Mills she made him feel safe.

Mills encouraged the husband to speak to his wife while she remained on the ventilators. She also encouraged him to connect with family, friends and their minister, keeping them in the loop and creating a system of support during his wife’s recovery.

The employer, who was self-insured, decided that the ongoing treatment would be covered.

“It was ruled compensable due to the fact she was undergoing surgery for a work-related claim,” said Mills. “The employer and TPA were fabulous in their support.”

When the patient stabilized, she was sent to a rehabilitation center for recuperation. After around three weeks, Mills decided she needed to be placed in a specialized facility where she could receive more aggressive therapy.

The patient had paralysis on her right side. She was aphasic, meaning her speech was limited to short sentences or repeated phrases, and her reading comprehension was low. Mills recommended sending the patient to Shepherd Center, a rehabilitation facility five hours away from where the patient and her family lived.

“Shepherd is on top of the newest research,” said Mills. It specializes in brain and spinal cord injury rehabilitation. “Each team meets weekly per patient — occupational therapy, physical therapy, speech therapy, physicians, nurses — they all work together. It’s a consistent meeting. It’s structured.”

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This type of hands-on care, she said, was what the patient needed most, but the patient was hesitant to go so far away from home. She had her good and bad days, said Mills. The stroke had really left a pressing mark on the patient and her confidence was shaken. Leaving her family behind was a tough decision to make.

But Mills persevered.

“Patients thrive at Shepherd,” she said. The NCM approached the patient’s husband and explained why the center was the best scenario and best chance for his wife’s recovery. He successfully convinced her to go.

Keeping Active

The patient remained at Shephard for two months.

“They would call me with what was going on,” said Mills. Communication between the center and the NCM was paramount in keeping the case moving forward and getting the patient back to her life. Mills was able to inform the patient’s employer on her progress and began coordinating home care before the patient even left the facility thanks to the continued line of communication.

When Shepherd saw the patient progressing in therapy, they moved her from a hospital room to an apartment on the center’s campus.

“That was key in helping her progress from feeling like a patient to living in the real world,” said Mills.

At home, Mills set up a full-time home care worker to be with the patient while she continued her occupational, physical and speech therapies, because the patient lived in a rural area and her therapies were about an hour away.

“Her husband would take her at first, but then the care giver would,” said Mills. “Her confidence was so shaken — just to talk to somebody would make her freeze up. As she got better, her confidence, independence and self-esteem improved.”

When OT, PT and speech therapy came to an end, however, it proved another hurdle for Mills’ patient.

“She came to the realization she had reached her maximum in therapy,” said Mills. The patient had gained back more of her speech but was still aphasic. She had learned how to use her left hand instead of her right, which was her dominant hand before the stroke, and her reading capability had returned, albeit slower than the patient expected.

“This was where she was going to be. She had to grieve for the loss of her life as it had been. But I told her that her life still had meaning and purpose. She could not give up. We would all be there to help her, but she needed to continue to do things around the house, in her church and in her community.”

A patient who lost use of her right hand began coloring to master control of her left hand.

With time and a lot of support from her husband, the patient did just that.

“She’s coloring,” said Mills. The pages the patient colors are from mandala designs, intricate and detailed patterns that are small and precise in shape. The patient, said Mills, has been coloring with her left hand, completely in the lines, and has sent Mills some of her finished pieces.

“Unfortunately, she will not work as a nurse due to the aphasia and limited use of her right hand,” said Mills. But she is able to volunteer at a local nursing home, where she helps with crafts and hands out refreshments.

“She even brings the mandala coloring books and pens for them to use, and they all work on them together,” she said.

Volunteering has opened the door for this patient to continue to recover mentally and emotionally. “She feels like she’s a part of something and is helpful and useful.”

Throughout recovery, Mills spoke with the husband on how to keep the patient active and push her to be as independent as possible. Her husband, said Mills, is the patient’s number one cheerleader.

Valuing Each Day

“We have the greatest impact when we get the file early on, so we can be there from the very beginning,” said Mills. She likes the face-to-face aspect of nurse case managing, where she sees her patients’ progress from day one till recovery.

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With this particular case, being there from the start was key in getting the patient back on her feet.

Insurers and employers, said Mills, have a bottom line — cost. But sometimes having the NCM on board from the start of injury can have a greater impact. The benefits of their service far outweigh the costs, she said.

“This patient went in thinking she was going to have a routine repair and would be back to work,” said Mills. “Aside from the physical [injury and recovery], I’ve learned a lot about the emotional impact and the fragility of life. But there is always tomorrow. It’s beautiful to see how she’s opened back up.”

When the stroke first happened, Mills recalled the patient’s husband was never frustrated or angry.

“He said he’s so grateful that she’s alive and that taught me something, too,” said Mills.

“It isn’t about what you had or what’s been taken away, it’s about what you do with what you’ve got now.” &

Autumn Heisler is the digital producer and a staff writer at Risk & Insurance®. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Risk Scenario

A Recall Nightmare: Food Product Contamination Kills Three Unborn Children

A failure to purchase product contamination insurance results in a crushing blow, not just in dollars but in lives.
By: | October 15, 2018 • 9 min read
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

PART ONE: THE HEAT IS ON

Reilly Sheehan, the Bethlehem, Pa., plant manager for Shamrock Foods, looks up in annoyance when he hears a tap on his office window.

Reilly has nothing against him, but seeing the face of his assistant plant operator Peter Soto right then is just a case of bad timing.

Sheehan, whose company manufactures ice cream treats for convenience stores and ice cream trucks, just got through digesting an email from his CFO, pushing for more cost cutting, when Soto knocked.

Sheehan gestures impatiently, and Soto steps in with a degree of caution.

“What?” Sheehan says.

“I’m not sure how much of an issue this will be, but I just got some safety reports back and we got a positive swipe for Listeria in one of the Market Streetside refrigeration units.”

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Sheehan gestures again, and Soto shuts the office door.

“How much of a positive?” Sheehan says more quietly.

Soto shrugs.

“I mean it’s not a big hit and that’s the only place we saw it, so, hard to know what to make of it.”

Sheehan looks out to the production floor, more as a way to focus his thoughts than for any other reason.

Sheehan is jammed. It’s April, the time of year when Shamrock begins to ramp up production for the summer season. Shamrock, which operates three plants in the Middle Atlantic, is holding its own at around $240 million in annual sales.

But the pressure is building on Sheehan. In previous cost-cutting measures, Shamrock cut risk management and safety staff.

Now there is this email from the CFO and a possible safety issue. Not much time to think; too much going on.

Sheehan takes just another moment to deliberate: It’s not a heavy hit, and Shamrock hasn’t had a product recall in more than 15 years.

“Okay, thanks for letting me know,” Sheehan says to Soto.

“Do another swipe next week and tell me what you pick up. I bet you twenty bucks there’s nothing in the product. That swipe was nowhere near the production line.”

Soto departs, closing the office door gingerly.

Then Sheehan lingers over his keyboard. He waits. So much pressure; what to do?

“Very well then,” he says to himself, and gets to work crafting an email.

His subject line to the chief risk officer and the company vice president: “Possible safety issue: Positive test for Listeria in one of the refrigeration units.”

That night, Sheehan can’t sleep. Part of Shamrock’s cost-cutting meant that Sheehan has responsibility for environmental, health and safety in addition to his operations responsibilities.

Every possible thing that could bring harmful bacteria into the plant runs through his mind.

Trucks carrying raw eggs, milk and sugar into the plant. The hoses used to shoot the main ingredients into Shamrock’s metal storage vats. On and on it goes…

In his mind’s eye, Sheehan can picture the inside of a refrigeration unit. Ice cream is chilled, never really frozen. He can almost feel the dank chill. Salmonella and Listeria love that kind of environment.

Sheehan tosses and turns. Then another thought occurs to him. He recalls a conversation, just one question at a meeting really, when one of the departed risk management staff brought up the issue of contaminated product insurance.

Sheehan’s memory is hazy, stress shortened, but he can’t remember it being mentioned again. He pushes his memory again, but nothing.

“I don’t need this,” he says to himself through clenched teeth. He punches up his pillow in an effort to find a path to sleep.

PART TWO: STRICKEN FAMILIES

“Toot toot, tuuuuurrrrreeeeeeeeettt!”

The whistles of the three lifeguards at the Bradford Community Pool in Allentown, Pa., go off in unison, two staccato notes, then a dip in pitch, then ratcheting back up together.

For Cheryl Brick, 34, the mother of two and six-months pregnant with a third, that signal for the kids to clear the pool for the adult swim is just part of a typical summer day. Right on cue, her son Henry, 8, and his sister Siobhan, 5, come running back to where she’s set up the family pool camp.

Henry, wet and shivering and reaching for a towel, eyes that big bag.

“Mom, can I?”

And Cheryl knows exactly where he’s going.

“Yes. But this time, can you please bring your mother a mint-chip ice cream bar along with whatever you get for you and Siobhan?”

Henry grabs the money, drops his towel and tears off; Siobhan drops hers just as quickly, not wanting to be left behind.

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“Wait for me!” Siobhan yells as Henry sprints for the ice cream truck parked just outside of the pool entrance.

It’s the dead of night, 3 am, two weeks later when Cheryl, slumbering deeply beside her husband Danny, is pulled from her rest by the sound of Siobhan crying in their bedroom doorway.

“Mom, dad!” says Henry, who is standing, pale and stricken, in the hallway behind Siobhan.

“What?” says Danny, sitting up in bed, but Cheryl’s pregnancy sharpened sense of smell knows the answer.

Siobhan, wailing and shivering, has soiled her pajamas, the victim of a severe case of diarrhea.

“I just barfed is what,” says Henry, who has to turn and run right back to the bathroom.

Cheryl steps out of bed to help Siobhan, but the room spins as she does so.

“Oh God,” she says, feeling the impact of her own attack of nausea.

A quick, grim cleanup and the entire family is off to a walk-up urgent care center.

A bolt of fear runs through Cheryl as the nurse gives her the horrible news.

“Listeriosis,” says the nurse. Sickening for children and adults but potentially fatal for the weak, especially the unborn.

And very sadly, Cheryl loses her third child. Two other mothers in the Middle Atlantic suffer the same fate and dozens more are sickened.

Product recall notices from state regulators and the FDA go out immediately.

Ice cream bars and sandwiches disappear from store coolers and vending machines on corporate campuses. The tinkly sound of “Pop Goes the Weasel” emanating from mobile ice cream vendor trucks falls silent.

Notices of intent to sue hit every link in the supply chain, from dairy cooperatives in New York State to the corporate offices of grocery store chains in Atlanta, Philadelphia and Baltimore.

The three major contract manufacturers that make ice cream bars distributed in the eight states where residents were sickened are shut down, pending a further investigation.

FDA inspectors eventually tie the outbreak to Shamrock.

Evidence exists that a good faith effort was underway internally to determine if any of Shamrock’s products were contaminated. Shamrock had still not produced a positive hit on any of its products when the summer tragedy struck. They just weren’t looking in the right place.

PART THREE: AN INSURANCE TANGLE

Banking on rock-solid relationships with its carrier and brokers, Shamrock, through its attorneys, is able to salvage indemnification on its general liability policy that affords it $20 million to defray the business losses of its retail customers.

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But that one comment from a risk manager that went unheeded many months ago comes back to haunt the company.

All three of Shamrock’s plants were shuttered from August 2017 until March 2018, until the source of the contamination could be run down and the federal and state inspectors were assured the company put into place the necessary protocols to avoid a repeat of the disaster that killed 3 unborn children and sickened dozens more.

Shamrock carried no contaminated product coverage, which is known as product recall coverage outside of the food business. The production shutdown of all three of its plants cost Shamrock $120 million. As a result of the shutdown, Shamrock also lost customers.

The $20 million payout from Shamrock’s general liability policy is welcome and was well-earned by a good history with its carrier and brokers. Without the backstop of contaminated products insurance, though, Shamrock blew a hole in its bottom line that forces the company to change, perhaps forever, the way it does business.

Management has a gun to its head. Two of Shamrock’s plants, including Bethlehem, are permanently shuttered, as the company shrinks in an effort to stave off bankruptcy.

Reilly Sheehan is among those terminated. In the end, he was the wrong person in the wrong place at the wrong time.

Burdened by the guilt, rational or not, over the fatalities and the horrendous damage to Shamrock’s business. Reilly Sheehan is a broken man. Leaning on the compassion of a cousin, he takes a job as a maintenance worker at the Bethlehem sewage treatment plant.

“Maybe I can keep this place clean,” he mutters to himself one night, as he swabs a sewage overflow with a mop in the early morning hours of a dark, cold February.

Bar-Lessons-Learned---Partner's-Content-V1b

Risk & Insurance® partnered with Swiss Re Corporate Solutions to produce this scenario. Below are their recommendations on how to prevent the losses presented in the scenario. This perspective is not an editorial opinion of Risk & Insurance.®.

Shamrock Food’s story is not an isolated incident. Contaminations happen, and when they do they can cause a domino effect of loss and disruption for vendors and suppliers. Without Product Recall Insurance, Shamrock sustained large monetary losses, lost customers and ultimately two of their facilities. While the company’s liability coverage helped with the business losses of their retail customers, the lack of Product Recall and Contamination Insurance left them exposed to a litany of risks.

Risk Managers in the Food & Beverage industry should consider Product Recall Insurance because it can protect your company from:

  • Accidental contamination
  • Malicious product tampering
  • Government recall
  • Product extortion
  • Adverse publicity
  • Intentionally impaired ingredients
  • Product refusal
  • First and third party recall costs

Ultimately, choosing the right partner is key. Finding an insurer who offers comprehensive coverage and claims support will be of the utmost importance should disaster strike. Not only is cover needed to provide balance sheet protection for lost revenues, extra expense, cleaning, disposal, storage and replacing the contaminated products, but coverage should go even further in providing the following additional services:

  • Pre-incident risk mitigation advocacy
  • Incident investigation
  • Brand rehabilitation
  • Third party advisory services

A strong contamination insurance program can fill gaps between other P&C lines, but more importantly it can provide needed risk management resources when companies need them most: during a crisis.



Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]