Patient’s death costs nurse his license

Posted June 04, 2010, at 9:38 p.m.

MACHIAS, Maine — The nursing supervisor who allowed a disoriented 61-year-old patient to leave the Down East Community Hospital during a severe snowstorm in January 2008 has lost his nursing license. The patient was found dead in a nearby snowbank the next day.

The Maine State Board of Nursing on Thursday revoked the nursing license of John Zablotny, 44, of Steuben for incompetent nursing practice and unprofessional conduct, Attorney General Janet T. Mills announced Friday.

“Nurses have a moral and ethical responsibility to use common sense and compassion to protect the patients that they care for,” Mills said. “Anything less puts patients’ lives at risk.”

Zablotny was the nursing supervisor on duty the night that Eastport resident Reid Emery, who was heavily drugged, asked to leave the 50-bed health care facility. Emery had been brought by ambulance to the hospital on Dec. 27, 2007, suffering from stomach pains. On Jan. 1, 2008, he began asking to leave.

That day, a snowstorm hit the area, and “nurses advised the patient he was too weak to leave the hospital, and that his family was not able to return to the hospital to provide him with transportation due to the storm,” says a statement from the Attorney General’s Office.

Even so, Zablotny provided Emery with discharge papers.

“The patient signed the discharge form, and Mr. Zablotny pointed the patient to the front exit of the hospital unescorted,” the attorney general’s press release states.

Before discharging Emery, Zablotny failed to review his medical records, which showed he was on medications, and therefore didn’t properly assess Emery’s medical condition, the nursing board determined. The nursing supervisor also ignored advice of other staff members that the patient was confused and weak, the press release states.

“Against the advice of hospital staff, Mr. Zablotny did not call the local police department,” it states. “He also did not verify that the patient had transportation or a specific destination and did not ensure that the patient was properly clothed.”

When Emery walked out into the storm, which had become a full-blown blizzard, it was around 8:20 p.m. and he was wearing a pair of brown slippers, socks, jeans and a flannel shirt. He was not wearing a jacket.

After learning that her husband had left the hospital, Emery’s wife pressed Zablotny until he called law enforcement for help.

Zablotny called the Regional Communications Center in Machias at 9:37 p.m. According to the center’s records, the nurse told the dispatcher that Emery had left the hospital and that the man’s wife was “demanding” he call police.

Dispatchers received three more calls from family members concerned that Emery had left the hospital heavily medicated and on foot.

When Machias Police Chief Grady Dwelley arrived at the hospital at 9:41 p.m., he learned Emery had left 90 minutes earlier.

Emery’s body was found the next day approximately 18 feet from the hospital’s side wall, near the neighboring veterans home. The medical examiner determined that he died of hypothermia and opiate toxicity.

Zablotny’s nursing license was revoked for two years and he must pay a $1,500 fine and the cost of the hearing. He is no longer working for Down East Community Hospital, Kate Simmons, a spokeswoman for Mills, said Friday.

“He has the right to appeal [the revocation] in Superior Court,” she said.

There is no telephone listing for Zablotny, and he couldn’t be reached for comment Friday.

An investigation by the federal Centers for Medicare & Medicaid Services into Emery’s death found, among a number of other deficiencies, that hospital staff had failed to meet the safety needs of the patient.

In response, DECH was given a conditional state operating license in 2008, but with quality improvements in the last two years, the hospital received full-license status in March.

The state also placed the hospital in receivership in July 2009, with Eastern Maine Healthcare Systems of Brewer taking over operations, and hospital administrator Douglas Jones has said he expects the receivership will last at least through the summer.

Emery was buried at Bayside Cemetery in Eastport.

“This is just a sad story,” Simmons said.

BDN writer Sharon Mack, former BDN writer Diana Graettinger and The Associated Press contributed to this report.

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