A Broward healthcare company nurse’s inexperience led to a child’s death, state says
The death of a 13-year-old girl while in the care of a nurse from a Fort Lauderdale area home healthcare company brought a state administrative complaint against the nurse’s license.
But the Sept. 14 complaint against Coral Springs’ Linda Rosembert also appeared to criticize Lauderhill’s Sierra Lifecare for assigning Rosembert even though “[Rosembert’s] resume did not demonstrate experience in care of medically-fragile, ventilator-dependent adolescents or children.”
The Florida Department of Health filing, depending on the violation and the history of the nurse, can end with anything from no punitive action from the state Board of Nursing to license revocation.
“Revocation” was the consequence for another Sierra nurse, Miramar’s Elayna Bash, just over a year ago. The state Board of Nursing accepted as fact the administrative complaints that Bash slept while on an in-home assignment taking care of a 4-year-old with a seizure disorder and then “used force” against that child. Bash’s license was revoked on Sept. 7, 2022.
As for the complaint against Rosembert, she had no comment when reached by phone. A phone call and emails from the Miami Herald to Sierra Lifecare haven’t been answered.
What the Florida Department of Health says happened
The complaint says that on Aug. 26, 2019, Sierra sent Rosembert to “provide home and school nursing care” for a 13-year-old girl who required a wheelchair and was “nonverbal, ventilator-dependent and fed by a gastrostomy tube.”
Despite what the complaint said about Rosembert’s resume, she had cared for the girl almost 10 months earlier.
This time, as she and the 13-year-old were on a school bus, the complaint said, bus video “demonstrates that the ventilator audio alarm sounded on multiple occasions.”
Each time, Rosembert “could be seen reaching behind the ventilator, at which time the alarm became silent. On interview, [Rosembert] stated that the ventilator did not have a “reset” button, but had a “silence” button, which she denied using.”
The complaint said Rosembert “failed to assess or document the presence, character or absence of [the girl’s] breath sounds.” Also, she didn’t check the girl’s blood pressure, oxygen saturations and other vital signs “other than one instance in which [Rosembert] noted ... oxygen saturation to be 94%, after [Rosembert] reportedly reconnected a ventilator filter.”
As Rosembert pushed the girl into class, the complaint said, the ventilator alarm was sounding. The teacher told Rosembert to take the girl to the school nurse.
The girl “was pale with discolored lips and no pulse” when they got to the school nurse, the complaint said. The nurse started CPR and called 911.
EMTs took the girl to the hospital, where she died at 9:13 a.m. that day.
The complaint says Rosembert:
▪ Shouldn’t have accepted the assignment because the 13-year-old’s needs were beyond Rosembert’s abilities.
▪ Should have documented the girl’s “vital signs, oxygen saturation and breath sounds” when the ventilator alarm sounded.
▪ Should have checked and noted the ventilator settings.
▪ “Ensure the presence and condition of a bag-mask valve at all times when caring for a ventilator-dependent patient.”
▪ “Provided ventilation by bag-mask valve if there’s a question whether the ventilator was functioning correctly.”
▪ Notified the girl’s mother and physician of the girl’s condition change.
