A nursing home patient died a tragic death after becoming entangled in his nightgown straps. The straps became wrapped around his bed causing strangulation. The patient's roommate tried to call the nurse when he realized the distress of the patient. The nurse did not come when called for 20 minutes.
When the nurse arrived the patient was blue and vomiting. Rather than perform CPR, the staff went to the patient's file to see if he was a DNR patient. He was not, but before the emergency crew arrived, he was already deceased. Several standards were violated in relation to CPR and the protocol that took place. Unfortunately, they allowed the patient to die. For more, read the story.