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Summary: As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes. When a family member is placed in a facility, a certain standard of care is expected. In this case, a resident was injured repeatedly while under their care. When the patient died a few days after being "dropped" the family sued.
The patient was a 95 year old woman who was placed in a Missouri nursing home when the family was no longer able to care for her needs.
"Approximately 1.5 million people live in the nation's 17,000 nursing care facilities. . .The typical nursing home resident is a woman in her 80s displaying a mild form of memory loss and dementia. Although physically healthy for a woman her age, she needs help with approximately 4 of 5 activities of daily living (eating, transferring, toiletting, dressing, and bathing)."2
During her admission the patient would sustain multiple injuries over the course of her stay. In 1993, on two occasions, the patient's legs were broken with fractures diagnosed. Each time the patient was transferred to the hospital for treatment and then returned to the nursing home.
Each time the documentation would show that the family had been "made aware." This was reflected in incident reports that had been filed. The incident reports did not specify which family members had been notified.
A third injury took place in 1995 when the patient was being transferred from her bed. Documentation of the incident stated that the patient had been "dropped" during a transfer. The charted notes documented that a head injury was sustained and that family members were notified.
The patient was again transferred to the hospital and was evaluated in the Emergency Department. Interestingly, when examined by a physician, the day after the incident, the physician stated that there was no evidence of head injury. Five days following this examination, the patient died.
The family would sue the nursing home. They would allege that standards of care had not been met. They would accuse the nursing home of rendering negligent care.
It is no secret that nursing home abuse occurs. It can take many different forms and have devastating consequences on residents and their families.
"The United States Department of Health and Human Services researchers identified seven categories of abuse. Ninety-five percent of those surveyed said they felt that all seven are problems for nursing home residents:
Physical abuse --infliction of physical pain or injury.
Misuse of restraints --chemical or physical control of a resident beyond physician's order or outside accepted medical practice.
Verbal/emotional abuse --infliction of mental or emotional suffering.
Physical neglect --disregard for the necessities of daily living.
Medical neglect --lack of care for existing medical problems.
Verbal/emotional neglect --creating situations harmful to the resident's self-esteem.
Personal property abuse --illegal or improper use of a resident's property for personal gain."3
The basis of the family's lawsuit centered on the assumption that a certain standard of care, and a "duty" is owed to nursing home residents. This duty it was assumed, included safe living conditions, freedom from harm and timely medical treatment. They alleged that these standards had not been observed by the nursing home.
In the initial trial, a review of the charting and documentation showed that in each "incident," facility protocols had been followed. Upon discovery of the injuries, medical treatment and family notification had been provided.
The Defense moved to have the charges dismissed. The court agreed.
The family appealed.
Questions to be answered.
1. Was there clear evidence of either neglect or abuse on the part of the nursing home staff in either of the three documented incidents of injury?
2. Had standards of care been met in regard to treating an injured patient and providing safe and reasonable care.
Chiefly due to the timely documentation of the incidents, the records were used to demonstrate adequate care being given.
The family's lawsuit chiefly targeted the "handling" of the incidents rather than the "cause" of injury. The documented interventions and notifications on the part of the nursing staff provided sufficient proof that standards were upheld.
It is common knowledge that documented nurses' notes and the medical chart are legal records. They should be written and treated at all times as if a jury will later examine them.
Had the incident not been documented as thoroughly or had incident reports not been filled out, it might have been a different story. It was the clear and concise charting of the nursing homes staff's handling of the incidents that saved the facility from a potentially costly lawsuit and trial.
This was particularly evident when the family accused the nursing home staff of "failure to notify" the family members. As long as efforts were documented in the notes to notify the family, the facility was covered.
It is a bit strange that the specifics as to "who" was notified was not included in the chart. Under a different set of opinions, this could easily be interpreted as a "red flag." In this case it was not.
This documentation of "notification" could have been seen as the nursing home staff charting to cover themselves regardless of whether a family member had been contacted.
To minimize suspicions of impropriety it is suggested that when a family member is contacted, the name and phone number also be documented. All evidence is subject to interpretation. This can be applied to physician notification as well.
When a patient has an attending, consulting physicians and residents responsible for their care, "MD made aware" leaves much room for debate as to who was notified. If the name of the physician is noted, the guesswork is removed and accountability easier to establish.
What was not addressed in this case was the nature of the "accidental" injuries. It is not difficult to imagine a 95-year-old patient falling as she tries to get out of bed. It is common for patients to fall on their way to or from the bathroom. The pertinent question is "could the injuries have been avoided."
It is clear from published studies that indeed many can be.
""We found that neither complaint investigations nor enforcement practices are being used effectively to assure adequate care for Nursing Homes residents and the prevention of nursing home abuse and neglect. As a result, allegations or incidents of serious problems, such as inadequate prevention of pressure sores, failure to prevent accidents, and failure to assess residents' needs and provide appropriate care, often go uninvestigated and uncorrected."4
Lawsuits against nursing homes are common and on the rise. If you are working in a nursing home, you need to be aware that you are responsible for documenting adequate care. You are equally responsible for prevention. If a dangerous condition or "accident waiting to happen" is identified, steps must be taken and documented to correct it.
If a patient is at risk for falling they may refuse to call for assistance. If they try to get out of bed anyway, it should be documented that the patient was instructed to "call for assistance," and did not.
If a patient is clearly a danger to himself or herself and others, restraints may be indicated. The family or the physician may refuse to allow or write an order for them. The nurse must document that the need for them was communicated, to whom and the response.
Even with adequate care being given accidents can happen with legal consequences. Nursing homes are currently the focus of intense governmental supervision and regulation. The effectiveness of the regulation is debatable. There are many that feel that the only "solution" to correcting problems are legal actions against nursing homes.
If this approach is to be paralleled to eliminating medical malpractice, a solution may be a long way off. What can be anticipated is increased pressure from the government, from consumers and the courts. This will result in increased litigation and increased pressure on nursing home staff and facilities. Each member of the nursing staff would be wise to document carefully daily care and especially incidents that result in injury.
Related Case Studies:
June 13, 1999: Felony Child Abuse Conviction, Made Possible Thanks to Nurse's Documentation.
State v. Gillard, 936 S.W. 2d 194 - MO (1999).
http://www.nursefriendly.com/nursing/clinical.cases/061399.htmJune 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Gordon v. Lewiston Hospital, 714 A.2d 539 - PA (1998)
http://www.nursefriendly.com/nursing/clinical.cases/060699.htmMay 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)
http://www.nursefriendly.com/nursing/clinical.cases/053099.htmRelated Link Sections:
Abuse:
http://www.nursefriendly.com/nursing/directpatientcare/abuse.htmClinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htmEmergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.htmlEthics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htmHead Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htmMechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htmNursing Homes, Long Term Care Links:
http://www.nursefriendly.com/nursing/nursing.homes.long.term.care.htm
Sources:
1. 40 RRNL 1 (June 1999)
2. American Health Care Association. September 1998. Profile: Nursing Facility Resident: Retrieved June 27, 1999 from the World Wide Web: http://www.ahca.org/secure/nfres.htm
3. Seniors-Site. No date given. Nursing Home Abuses to Senior Citizens. Retrieved June 27, 1999 from the World Wide Web: http://seniors-site.com/nursing/abuses.html
4. United States Senate. March '99. Excerpts from Committee On Aging Hearings. Retrieved June 27, 1999 from the World Wide Web: http://www.jeffdanger.com/
The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/062799.htmSend comments and mail to Andrew Lopez, RN Created on Saturday May 23, 1999
Last updated by Andrew Lopez, RN on Saturday, September 17, 2011
Tuesday, December 6, 2011
Elderly Patient Repeatedly Injured In Nursing Home "Accidents." Negligence, Coincidence or Abuse? #nursefriendly #nursecasestudy #elderly #geriatrics
Monday, November 21, 2011
Patient Left Unrestrained, #Patient Injured. #Nurses Judgement Call, #nursing #malpractice #nursefriendly #epatient #negligence
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Please send a blank e-mail to: clinicalnursingcases-subscribe@topica.comSummary: The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued.
The patient was involved in a motor vehicle accident. A head injury was suffered leaving him in a state of confusion and prone to agitation.
"Each year, an estimated 2 million people sustain a head injury. About 500,000 to 750,000 head injuries each year are severe enough to require hospitalization. Head injury is most common among males between the ages of 15-24, but can strike, unexpectedly, at any age. Many head injuries are mild, and symptoms usually disappear over time with proper attention. Others are more severe and may result in permanent disability." 2
Following the head injury, the patient was visibly confused and frequently became agitated. During the course of his admission, an order for "soft" wrist restraints was obtained and implemented to protect the patient from injury related to mental status (personality) changes.
"Personality Changes-Apathy and decreased motivation. Emotional lability, irritability, depression. Disinhibition which may result in temper flare-ups, aggression, cursing, lowered frustration tolerance, and inappropriate sexual behavior."2
On the day of the incident, the nurse on duty had assessed the patient. In her professional opinion restraints were not needed.
"What Is Restraint?
"Restraint" is physical force, mechanical devices, chemicals, seclusion, or any other means which unreasonably limit freedom of movement. hospital staff may use four types of restraint to restrict patients who are acting, or threatening to act, in a violent way towards themselves or others.
Physical restraint--holding a patient for over five minutes in order to prevent freedom of movement.
Mechanical restraint--using a device, such as 4-point or full sheet restraint, to restrict a patient's movement (excludes devices prescribed for medical purposes).
Chemical restraint--medicating a patient against her will for the purpose of restraint rather than treatment.
Seclusion--placing a patient alone in a room so that she cannot see or speak with patients or staff and the patient cannot leave or believes she cannot leave."3
She based this decision on her observation of the patient's mental, physical state and level of consciousness. It is common procedure and protocol in facilities for patient's to be released from restraints when the danger of violence is felt to have passed.
"How Long May Restraint Continue?
When an emergency no longer exists, the patient should be released. Thus, staff should release a patient who, upon examination, appears calm. The total time which a patient may be restrained is limited:"3
Later in the shift, the same nurse was helping the patient get up. In the course of this maneuver, the patient fell and claimed that an injury was sustained.
A lawsuit would be filed against the facility alleging negligence on the part of the nurse. The patient contended that the removal of the restraints breached standards of care.
In the initial trial, the jury was instructed to view the nurse's role as an "error in judgement." Based on this and on testimony on the proper use of restraints, standards of care, the court found for the facility.
The patient appealed.
Questions to be answered:
1. Was the nurse in error to remove the restraints from a patient when she felt they were no longer needed.
2. Did the removal of the restraints directly contribute to the "injury" that the patient claimed to sustain?
3. Were the standards of care governing restraint use adequately maintained?
The plaintiff's arguments sought to convince the jury that poor judgement was exercised by the nurse. It was contended that removal of the restraints and ambulation of the patient put him in harm's way.
With the patient assessed to be calm, the purpose of the restraints, "to prevent the patient from harming himself or others," had been achieved.
The purpose of the restraints had not been to "keep the patient from falling out of bed." The removal of the restraints then, could not be deemed as negligent. There was no duty of care breached in allowing the calm patient to remain unrestrained.
The order was in place to ambulate the patient when stable. In the nurse's opinion, the patient was ready. Another nurse may not have agreed with her actions. The patient under a different nurse's care might have been kept in restraints. A nurse could have "held off" on the order to ambulate.
There was no causative relationship between removing the restraints and the patient's fall. In carrying out orders for ambulation, the nurse was providing proper nursing care.
It's not difficult to picture a lone nurse with an unsteady patient losing control and having the patient slip away. Would this be a breach of duty owed to the patient?
One could argue that the nurse had no business trying to move a patient by herself. One might also observe the staffing patterns at the time and realize the nurse was doing "the best she could."
The decision to remove the restraints was clearly a nursing decision. Often the decision to use them in the first place lies with the nurse too.
This illustrates the leeway and discretion given nurses when carrying out physician's orders. It also shows the typical catch 22 situation some nurses may find themselves in regarding restraint use.
"Historically, conventional wisdom supported using physical restraints, including bed side rails, to "protect and safeguard" residents. Ironically, little documented evidence exists that restraints prevent falls and risk of injury from falls. Clinical studies demonstrate that restraints, conversely, in some instances, precipitate or exacerbate fall risk."4
Both nurses in the above situation would be acting within their scope of practice. Each would be adhering to standards of care.
For the plaintiff to have a case, it would need to proven that either the removal of the restraints or the ambulation of the patient was premature.
This was clearly not the case. The actions of the nurse were in good faith and exercised reasonable concern for the well being of the patient. The fact that the patient suffered a fall is unfortunate, and reasonably unforseeable.
It can be compared to the actions of a physician when dealing with an acute patient. Depending on which course of treatment that physician chooses, the patient might or might not have a favorable outcome.
In either case, as long as the physician exercises reasonable judgement based on established principles of practice, a finding of negligence is unlikely.
It has been well established that Medicine is not an exact science. Outcomes are not guaranteed when prescribing courses of treatment.
They are the result of standard medical practices and individual patient responses. These responses are not always predictable. Basically, the caregiver can only hope for the best.
The same principle applies to Nursing care. Regardless of how accurate assessments are and how diligently orders are carried out, patients may or may not experience favorable outcomes.
When outcomes are unfavorable, it is the constitutional right of the patient or patient's estate to sue anyone felt to be involved.
The court reviewed the facts of the case and a nursing expert's testimony on restraint use. The appeals court agreed that standards of care had been maintained.
There exists today intense pressure from family members, governmental agencies and regulatory agencies to limit restraint use to "only when absolutely necessary." As soon as they are put in use, the plan of care must include provisions for their removal.
Link Sections:
Head Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htmEthics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htmMechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...Medical Legal Consulting Nurse Entrepreneurs
http://www.nursefriendly.com/nursing/ymedlegal.htmSources:
1. RRNL 2 (July 1997)
2. Family Caregivers Alliance Clearinghouse. Revised November 1996. Fact Sheet: Head Injury. Retrieved May 30, 1999 from the World Wide Web: http://www.caregiver.org/factsheets/head_injury.html
3. Mental Health Legal Advisors Committee. No date given. Your Rights in Hospitals Regarding Restraining and Seclusion. Retrieved May 30, 1999 from the World Wide Web: http://www.psychiatry.com/mhlac/basicrights/restraintandseclusion.html
4. Braun, Julie A. & Quish, Clare J. 11/10/98. Illinois Institute for Continuing Legal Education. Physical Restraints And Fall-Related Injuries. Retrieved May 30, 1999 from the World Wide Web: http://www.iicle.com/articles/braun11_10_98b.html
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Tuesday, August 16, 2011
amednews: Revealing their medical errors: Why three doctors went public :: Aug. 15, 2011 ... American Medical News
In September 2010, Kimberly Hiatt made a medical error. The critical care nurse at Seattle Children's Hospital miscalculated and gave a fragile 8-month-old baby 1.4 grams of calcium chloride, 10 times the correct dose of 140 milligrams.
The mistake contributed to the death of the child and led to Hiatt's firing and an investigation by the state's nursing commission. In April 2011, devastated by the loss of her job and an infant patient, Hiatt committed suicide.
Hiatt, who had worked as a nurse for more than two decades, was another in a long line of "second victims" of medical error, the term used in medical literature to describe physicians and other health professionals who often feel guilty and depressed after adverse events. Many physicians and other health professionals hold themselves to a standard of perfection, and when things go wrong, they feel alone.
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Tuesday, June 14, 2011
Sheriff to serve 100 days, lose license for retaliating against nurses - Mywesttexas.com: Top Stories
Winkler County Sheriff Roberts L. Roberts will serve 100 days in jail and lose his Texas Peace Officers License for retaliating against two whistleblower nurses, a judge order Tuesday.
Visiting Judge Robert Moore handed out the punishment in a Midland County court Tuesday afternoon after the sheriff was found guilty of six charges in the case: two third-degree felony counts of retaliation, two third-degree felony counts of misuse of official information, and two class A misdemeanor counts of official suppression.
Roberts faced up to 10 years in prison on the charges. Moore however sentenced the sheriff to four years in prison, which were suspended for four years of probation; 100 days in Winkler County jail, which the sheriff will serve; a $1,000 fine for each charge ($6,000 total); a removal from office as sheriff; a waive of his right to an appeal; and a permanent surrender of his Texas Peace Officers License.
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Tuesday, May 17, 2011
Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?
ShareThis See also: Medical, Legal Nurse Consultants, Clinical Nursing Case of the Week, Clinical Charting and Documentation, Nurses Notes, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:
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Summary: Nursing homes are frequently a patient's destination for
rehabilitation following surgery. Common conditions fitting
this bill include large bone fractures, hip replacements and stroke.
Following these acute episodes, the patients are too unstable to
go home and not "sick" enough to have their hospital stays
reimbursed by insurance companies. The purpose of admission
to a nursing home is to help the patient regain lost function,
strength and health. In this case, the patient would remain in the
Nursing Home till her death of complications.The patient was admitted to a state owned nursing home
following repair of a femoral fracture. Her treatment plan
emphasized Physical, Occupational therapy and Nursing care
to provide for rehabilitation.She had successfully undergone surgery to repair a fractured
femur. The length of stay projected was six weeks. During
this time, the patient's condition would worsen rather than
improve.This is not an isolated incident. Media attention is continuously
focusing on conditions in nursing homes."A TIME investigation has found that senior citizens in nursing
homes are at far greater risk of death from neglect than their
loved ones imagine. Owing to the work of lawyers, investigators
and politicians who have begun examining the causes of
thousands of nursing-home deaths across the U.S., the grim
details are emerging of an extensive, blood-chilling and for-profit
pattern of neglect."2The patient's skin was intact and she was continent on admission.
She would develop multiple pressure ulcers on her bony
prominences. These are frequently the consequence of inadequate
turning and poor nutrition. Monitoring of both of these factors
are direct responsibilities of nurses and nursing home personnel.
If either is inadequate, a duty is owed to the patient by the nurse
to inform the physician. The physician, once made aware, is
then charged with taking additional measures as needed.The patient would have a Foley catheter inserted supposedly
for urinary incontinence. Documentation would later show
that need for catheterization had not been established.The patient had been fully continent on admission. Her
rehabilitation plan called for her to ambulate to the bathroom
when needed. An assessment of her ability to go on her own
was nowhere to be found at the time of her Foley catheter
insertion. Development of a urinary tract infection is a known
complication of catheter use. The patient would develop a
UTI soon after."In the last year, complaints against nursing homes in Texas
are up over 60%. Medication errors, under-staffing, unsanitary
conditions, neglect, lack of care, substandard care and injuries
from dangerous products, are but a few of the dangers. The
administrators of these facilities contend that the level of care
is excellent in Texas nursing homes but, state investigators and
Texas juries have been sending a different message."3On the initial trial, the court dismissed the claims. They based
this on the fact that the nursing home personnel were "state"
employees and supposedly immune from liability.The patient's family appealed.
Questions to be answered:
1. Could the nursing home personnel in a public facility be
held liable for negligence in the care of the patient?
Specifically, could they be sued for not maintaining the
standards of care required by the state?2. Were the "incidents" leading up to the patient's deterioration
reasonably "foreseeable" by a prudent caregiver in a
similar situation?On appeal, the plaintiff presented multiple pieces of evidence
documenting neglectful incidents.This documentation included fractures during transfers (one
requiring re-hospitalization and extensive surgical repair),
the development of skin breakdown, the development of
infections of the respiratory, urinary and gastrointestinal tract.Each of these events suggested that care for the patient could
be falling below accepted standards. Each of these events
could be identified as necessitating further therapy and
increasing the patient's length of stay.In reviewing the Tort Immunity Acts of Illinois, it was
determined that liability could be assessed for acts of
negligence or omission in the patient's care.It was clear from physical, mental and health status changes
that the patient was deteriorating. These changes, specifically
the multiple injuries during transfers, development of skin
breakdown and infection could be traced to negligence in the
omission of required care. Any time the treatments prescribed
by the physician are not carried out, or if it is not documented
that they have been carried out, the possibility of omission and
negligence is raised.It is highly unlikely that if the treatments and care prescribed
had been given that the gross deterioration would have occurred.
In this case, documentation of care was not present. Documentation
of "likely results of neglect" was present.This underscores the necessity of properly documenting the care
you give. Many facilities are adopting "charting by exception"
policies. These are dangerous in that they may not account for
basic care given. In saving time and nursing costs for a facility,
not fully charting care given can raise the question of a nurse's
omission and negligence later in court.If the temptation to chart care that is not given is present, keep
this in mind.If time for giving proper treatments and care is not there,
falsifying records is patently illegal. It is an offense that
could cost you your license if reported to the State Board.In the case of a lawsuit, it is much cheaper for a facility to
scapegoat a nurse, than defend one. If reporting you to the
State Nursing Board, or threatening to will give their attorney's
a bargaining chip to keep an employee "quiet," about existing
conditions they'll use it."Generally, the nursing-home industry likes to settle lawsuits
quietly and often hands over money only in exchange for
silence."2A nurse must decide if saving facility money by spending
less time charting or on patient care is worth possible liability
or loss of licensure down the road. It is highly unlikely that
a nursing home or hospital will defend a nurse named in a
lawsuit. This chiefly will happen only when the facility's
assets are at stake.If conditions in a nursing home are visibly substandard, a
nurse must ask if it is wise to continue working in the facility.
Ask yourself. Is the administration receptive to suggestions
for improvement? Do they raise concerns over overtime and
time involved to complete care and charting?As media attention and lawsuits increase, more nurses will
find themselves involved in legal actions. If it's determined
that poor conditions existed yet nothing was done about
them, the cost in liability could be high."Palo Alto attorney Von Packard has studied the death
certificates of all Californians who died in nursing homes
from 1986 through 1993. More than 7% of them succumbed,
at least in part, to utter neglect--lack of food or water,
untreated bedsores or other generally preventable ailments.
If the rest of America's 1.6 million nursing-home residents
are dying of questionable causes at the same rate as in
California, it means that every year about 35,000 Americans
are dying prematurely, or in unnecessary pain, or both."2Many states have "elder abuse" legislation mandating abuse
be reported. Whistle blower legislation is slow in coming.
Currently the employer's interests are put first rather than the
patient's or employees in most cases. Protections for nurses
that do report abuse are questionable in their effectiveness.
The risk of employer retaliation is high.The chances of a nursing home or hospital defending you
against the State Board of Nursing when your license is
at stake over an incident are almost none. In fact, it is
common for complaints to be filed by the facility where
a nurse has worked.Unless you have a personal malpractice insurance policy,
you will be forced to pay for this representation out of pocket.
For less than the cost of a typical day's pay (around $70-$90
per year), most personal policies will provide representation at
no additional cost to you.Related link Sections:
Direct Patient Care Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htmEthics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htmFoley Catheterization:
http://www.nursefriendly.com/nursing/directpatientcare/foley.catheterization.htmInformed Consent:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.co...Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htmOperating Room (Surgical) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directory/spec/operatingroom.htmNursing Homes, Long Term Care Links:
http://www.nursefriendly.com/nursing/nursing.homes.long.term.care.htmWound Care:
http://www.nursefriendly.com/nursing/directory/business/woundcar.htmSources:
1. 39 RRNL 12 (May 1999)
2. Time Magazine. October 27, 1997. Fatal Neglect. Retrieved July 11, 1999 from the World Wide Web: http://cgi.pathfinder.com/time/magazine/1997/dom/971027/nation.fatal_neglect....
3. Law Offices of James K. Burnett, P.C. 1999. Nursing Home Negligence. Retrieved July 11, 1999 from the World Wide Web: http://www.nursinghomenegligence.com/
The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/071199.htmSend comments and mail to Andrew Lopez, RN Created on July 11, 1999
Last updated by Andrew Lopez, RN on Monday, February 28, 2011
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#Diabetic Coronary Artery Bypass #Patient, Septic & Noncompliant. #Nursing Duty and Responsibility Questioned.
ShareThis See also: Medical, Legal Nurse Consultants, Clinical Nursing Case of the Week, Clinical Charting and Documentation, Nurses Notes, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:
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Summary: Patient noncompliance can present serious challenges to
nurses and physicians providing care. If aware of the proper measures
to be taken, what happens when the patient does not agree
or comply with the course of treatment? In this case, a patient after
having a coronary artery bypass grafting developed a sternal infection.
When advised by a nurse to return for treatment, the patient refused.The patient was known to have Insulin-Dependent Diabetes Mellitus.
She would seek medical attention with a history of Angina (chest
pain). Following the episode, she was referred for a diagnostic
cardiac catheterization."According to latest statistics from the American Heart Association,
roughly 323,000 cardiac catheterizations were performed in the
United States in 1994. The procedure provides doctors with
information about the heart's structure and its ability to function.
Doctors may also use catheterization to perform procedures on the
heart, such as balloon angioplasty.To perform a cardiac catheterization, a thin catheter is inserted
through a small puncture wound in a blood vessel -- usually the
femoral artery in the leg. Using X-rays for guidance, doctors feed the
catheter through the circulatory system until it reaches the heart."2Following the catheterization, an emergent multiple bypass surgery
was recommended by the Cardiologist."What is coronary artery bypass surgery?
A coronary artery bypass graft operation is a type of heart surgery. It
is sometimes referred to as CABG or "cabbage." The surgery is done
to reroute, or "bypass," blood around clogged arteries and improve the
supply of blood and oxygen to the heart. These arteries are often
clogged by the buildup over time of fat, cholesterol and other
substances.The narrowing of these arteries is called atherosclerosis. It slows or
stops the flow of blood through the heart's blood vessels and can lead
to a heart attack."3The patient would refuse and left the hospital Against Medical Advice
(AMA). Three days later the patient would return to the hospital and
provide an Informed Consent to the operation. It was performed by
the Facility's Cardiac Surgery Director assisted by a fourth year
resident.""Revascularization with coronary artery bypass graft surgery
(CABG) and percutaneous transluminal coronary angioplasty (PTCA)
is well accepted as a method of relieving anginal pain and thus
improving quality of life. In addition, CABG has been shown to
improve survival in certain subgroups of patients with coronary
disease, which has led to the widespread use of this procedure in
revascularization. In 1991 407 000 bypasses and 303 000 PTCA
procedures were performed.1 Currently, coronary atherectomy,
various laser techniques, and coronary stents are being evaluated as
additional approaches to revascularization."4Following the coronary artery bypass grafting, the patient would
remain in the hospital for ten days.The patient would return for a follow-up visit just under two weeks
later with the surgeon. Assisted by a cardiac nurse, the midsternal
incision was examined, staples were removed. A portion was found
to be purulent, draining and healing poorly.Cultures were obtained and sent, the patient would be scheduled for
another follow up visit a month later.Four days later, the patient spiked a temperature. She called the
medical center and spoke to the nurse who had assisted the surgeon.
After listening to the patient's complaints, the nurse instructed her to
return to the medical center for treatment. She informed the patient
that her test results had come back and multiple infections had been
discovered from the midsternal wound in her chest."Approximately 2% to 20% of CABGs are complicated by a surgical-
site infection (SSI).4,5 Much of the literature on SSI following
cardiothoracic surgical procedures focus on deep chest infections,
which, although not frequent (complicating 0.5% to 5% of cardiac
procedures4,5), are important because of the high morbidity,
mortality, and immense costs they add to the healthcare system."5The patient refused. She stated that it was almost an hour's drive to go
to the medical facility. In her "condition" she didn't feel she could
"make" the trip.She asked the nurse if antibiotics could be "prescribed over the phone"
and started without her being evaluated. The nurse informed her this
was not an option.The nurse informed the patient that it would be best for her to return
to the facility where the operation had been performed. If she
returned her condition could be evaluated and treatment initiated. The
patient still refused.Alternatively the nurse stated that the patient should seek immediate
medical assistance and contact her local physician.The patient was unable to contact a local physician and did not go to
the Emergency Room immediately. In fact, the patient was not
examined by her physician until almost ten days later.At that time, ten days after the known Insulin Dependent Diabetic
patient had been informed by the nurse that she had a potentially life
threatening multiple organism infection in her chest, she was
readmitted to a local hospital."Surgical-site infection of the sternal wound includes superficial SSI,
deep sternal SSI, sternal osteomyelitis, mediastinitis, and endocarditis.
These often have been pooled together in the analysis of risk factors.
Host intrinsic risk factors that have been linked specifically to SSI of
the sternal wound include obesity,4,9-11 diabetes mellitus,4,9-13
current cigarette smoking,9 and steroid therapy,13 the former two risk
factors being the most frequently reported (Table 1). Kluytmans and
colleagues further demonstrated that the risk of developing SSI was
higher in the diabetic patient using insulin therapy than in the diabetic
patient treated with oral agents.12"5A sternal infection was verified. The patient would require
readmission and surgery to debride the wound and bring the infection
under control. Part of her sternum would be removed in the process.At the patient's request, the course of events was examined by the
Physician Medical Review Board. She alleged that standards of care
had not been maintained. She stated that negligence on the part of the
surgeon and the nurse had led to her infection and subsequent surgery.The board dismissed the complaint. They stated there was no clear
evidence of wrongdoing or negligence on the part of the nurse or
physician.The patient filed a lawsuit regardless against the physician, facility
and the nurse accusing negligence. The case was dismissed.The patient appealed.
Questions to be answered:
1. Did the nurse fail to observe the applicable standards of care in her
conversation with the patient?2. Was the nurse giving the patient "medical advice" when she
advised her to return for treatment?3. Did the nurse mislead the patient or make any statements that could
have contributed to the patient's complications?The physicians and the court when reviewing the nurse's performance
agreed it was appropriate. The nurse was dealing with a known septic
patient with a history of noncompliance. She instructed and
emphasized to the patient that an infection was present and required
treatment.The nurse advised the patient of where the best treatment could be
obtained. The patient was notified that if she could not return
immediately, that treatment should be sought elsewhere on an
emergent basis.The nurse was giving medical advice. In this case, the nurse was
telling the patient exactly what a competent surgeon would have told
her as well.This is a special situation involving a nurse with advanced skills and
experience in a nursing specialty. Nurses with specialized training are
recognized as competent to advise patients on pre-defined situations
according to their level of expertise.A midsternal infection is a known complication of coronary artery
bypass grafting. The nurse being aware of this was appropriate in her
counseling of the patient to seek immediate care.The nurse in the eyes of the law would be and was held to the same
standards as a physician in the advice that was given. The nurse did
in fact, maintain the standards of care expected in the situation.Her responsibility or "duty" to the patient was to advise her of the
medical condition present (a septic infection), make recommendations
for treatment (return to the hospital), inform her of consequences of
not being treated and present alternatives.This duty was fulfilled and recognized repeatedly by the medical
review panel and the courts. It is unfortunate that the noncompliant
patient decided to pursue litigation regardless.It demonstrates clearly how vulnerable even the most prudent nurses
are to being sued. Often it is the case that nothing has been done
wrong, nor is there negligence likely. It's a constitutional right for an
individual to initiate a lawsuit for real or perceived losses.Makes an excellent case for carrying a malpractice insurance policy.
For the cost of a typical day's pay, you can have protection against
lawsuits without having to depend on an employer's policy being
adequate to protect you.Related Link Sections:
Cardiac Arrhythmias Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/symptoms/cardiac.arrhy...Cardiac Catheterization (Diagnostic) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/tests/cardiac.catheter...Cardiac Links, Direct Patient Care on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/cardiac.htmClinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htmCoronary Artery Bypass Grafting (CABG) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/cardiac/coronary.arter...Direct Patient Care Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htmEmergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.htmlEthics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htmHead Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htmInformed Consent:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.co...Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htmOperating Room (Surgical) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directory/spec/operatingroom.htmSources:
1. 40 RRNL 1 (June 1999).
2. WTVC NewsChannel 9. 1999. Cardiac Catheterization: http://www.newschannel9.com/healthwatch/hw594.html
3. The American Heart Association. 1999. Bypass Surgery, Coronary Artery: Retrieved July 4, 1999 from the World Wide Web: http://www.amhrt.org/Heart_and_Stroke_A_Z_Guide/bypass.html
4. American Heart Association. 1994. Optimal Risk Factor Management in the Patient After Coronary Revascularization. Retrieved July 4, 1999 from the World Wide Web: http://www.amhrt.org/Scientific/statements/1994/129401.html
5. Infection Control & hospital Epidemiology. April 1988. Surgical-Site Infections After Coronary Artery Bypass Graft Surgery: Discriminating Site-Specific Risk Factors to Improve Prevention Efforts. Retrieved July 4, 1999 from the World Wide Web: http://www.slackinc.com/general/iche/stor0498/edit.htm
See also:Comparison Shopping
Children and Infants, Clothing and Fashion Accessories, Credit, Financial and Lending, Health & Beauty Aids, Travel, Hobby & Leisure,
Housewares, Home and Garden
The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/070499.htmSend comments and mail to Andrew Lopez, RN Created on July 4, 1999
Last updated by Andrew Lopez, RN on Monday, February 28, 2011
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******************************************************
Sincerely,
Andrew Lopez, RN
Nursefriendly, Inc. A New Jersey Corporation.
38 Tattersall Drive, Mantua New Jersey 08051
http://www.nursefriendly.com info@nursefriendly.com ICQ #6116137
856-415-9617, (fax) 415-9618
150,000 + Nurse-Reviewed & Approved Nursing Links
http://www.4nursing.com
http://www.inspirationalnursing.com
http://www.legalnursingconsultant.com
http://www.nursefriendly.com
http://www.nursingcasestudy.com
http://www.nursingentrepreneurs.com
http://www.nursingexperts.com
http://www.nursinghumor.com
