Nurse Advises "Reconsider Choice of Physicians" An Nurse's Ethical Dilemma. Robert W. Stein, III, RN, MSHA, CHE, #nurseup

Nurse Advises "Reconsider Choice of Physicians" An Nurse's Ethical Dilemma. Robert W. Stein, III, RN, MSHA, CHE, LNC:"In this case the nurse providing patient care noted a decline in the patient's condition, evidenced by weight loss, hallucinations, psychiatric symptoms, and acute distress. The findings were documented and attempts were made to contact the attending physician. The attending physician, however, failed to return any of telephone messages.
As the patient's condition continued to deteriorate, the patient's family asked for the nurse's advice about what should be done for the patient. The nurse suggested that they "reconsider the choice of physicians."
The facility promptly fired the nurse after learning of the advice she had given to the patient's family. The nurse brought suit for wrongful termination arguing that as a Registered Nurse she was obligated to provide "teaching and counseling" to her patients and their families."
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Elderly Patient Repeatedly Injured In Nursing Home "Accidents." Negligence, Coincidence or Abuse? #nursefriendly #nursecasestudy #elderly #geriatrics

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:  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.htm

June 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.htm

May 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.htm

Related Link Sections:

Abuse:
http://www.nursefriendly.com/nursing/directpatientcare/abuse.htm

Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Emergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.html

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Head Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htm

Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Nursing 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.htm

Send comments and mail to Andrew Lopez, RN

Created on Saturday May 23, 1999

Last updated by Andrew Lopez, RN on Saturday, September 17, 2011

via nursefriendly.com

Patient Left Unrestrained, #Patient Injured. #Nurses Judgement Call, #nursing #malpractice #nursefriendly #epatient #negligence

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:

Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Attorneys, Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material.

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Summary: 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.htm

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...

Medical Legal Consulting Nurse Entrepreneurs
http://www.nursefriendly.com/nursing/ymedlegal.htm

Sources:

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

The Uniform Resource Locator (URL) or Internet Street Address of this page is
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#Elderly #Patient Repeatedly Injured In #NursingHome "Accidents." #Negligence, Coincidence? http://bit.ly/sFOyRe #nursefriendly

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:

Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Attorneys, Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material.

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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.htm

June 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.htm

May 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.htm

Related Link Sections:

Abuse:
http://www.nursefriendly.com/nursing/directpatientcare/abuse.htm

Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Emergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.html

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Head Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htm

Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Nursing 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.htm

Send comments and mail to Andrew Lopez, RN

Created on Saturday May 23, 1999

Last updated by Andrew Lopez, RN on Saturday, September 17, 2011

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Nurse Sued For "Too Many Sticks" How Many Attempts Is Too Many?

Clinical Nursing Malpractice Case Studies, January 29, 2002
Coleman v. East Jefferson General Hosp., 747 So.2d 1044- LA (1999)

Summary: Starting Intravenous Lines and Performing Venipunctures are basic nursing skills in the Acute Care or Hospital settings. In this case, a female patient would accuse a male nurse of negligence and causing a resulting injury when he needed three attempts to successfully start an intravenous catheter.

The female patient came to the hospital with vague complaints of abdominal pain and was evaluated in the Emergency Department. The physician’s orders for treatment included intravenous medications for which a line would need to be started.

“Up to 90% of patients who require health care services need some form of I.V. therapy. Unfortunately, many hospitals have done away with I.V. teams, so you may be responsible for inserting and maintaining I.V. lines even if you're inexperienced or have limited opportunities to keep your skills sharp.”2

*************************
Sidebar:

Venipuncture and the insertion of intravenous catheters are basic nursing skills. If a nurse has not learned these skills in Nursing School, it will be often be learned “on the job” in the early months of orientation at an acute care facility.

As with most nursing skills, it is one that improves with practice. The prudent nurse will attempt once or twice and then ask another nurse to give it a try.

In rare cases, you will come across patient’s that are “a difficult stick.” In this case, if there simply are “no veins” the physician should be notified or an expert nurse should be called in.

*************************

A male nurse was assigned to the patient when the Intravenous Catheter was to be placed. The nurse was having difficulty finding veins in the woman’s arms. He then attempted twice to start a line in her hand and was successful on the third attempt.

It was the policy of the hospital at that time, that a nurse may attempt an intravenous catheter insertion no more than two times before calling for assistance.

For the remainder of the patient’s treatment at the hospital, it would be documented that the patient complained of discomfort at the IV site and tolerated it poorly.

Pain or discomfort at the site of an IV insertion should present a “red flag” to an experienced nurse.

When combined with redness, swelling, puss or exudates at an IV site, pain can signal one of many potential complications of Intravenous Therapy including extravasation of IV fluids/medication, infection of the site or a dislodging of the catheter.

When pain or potential complications are reported, the site should be thoroughly evaluated for signs of a problem. If symptoms persist, the placement of another line at an alternate site should be offered for continued Intravenous Therapy.

There was no indication in the hospital record, that other signs/symptoms of a complication existed other than the pain/discomfort. This may have been positional due to the location of the IV site in the patient’s hand.

There was no indication that placement of another line was either offered to, or refused by the patient.

“When an I.V. lawsuit is argued in court, top-notch I.V. skills don't mean much unless they're backed up by appropriate, accurate, and concise documentation. Unfortunately, documentation is where many nurses fall short.”2

Following her discharge, the patient would file a suit alleging negligence on the part of the nurse and hospital. Specifically, she claimed a poorly performed catheter insertion caused her to develop Reflex Sympathetic Dystrophy in her right hand.

“What is Reflex Sympathetic Dystrophy Syndrome?

Reflex sympathetic dystrophy syndrome (RSDS) is a chronic condition characterized by severe burning pain, pathological changes in bone and skin, excessive sweating, tissue swelling, and extreme sensitivity to touch. The syndrome is a nerve disorder that occurs at the site of an injury (most often to the arms or legs). It occurs especially after injuries from high-velocity impacts such as those from bullets or shrapnel. However, it may occur without apparent injury.”3

Summary judgment was entered for the hospital finding that no negligence was evident.

The patient appealed.

Questions to be answered:

1. Was the nurse negligent in his catheter insertion technique? Were certifications and hospital policies/procedures adhered to?

2. Were standards of care, specific to Intravenous Catheter Insertions adhered to.

3. Was it plausible, that the patient’s “Reflex Sympathetic Dystrophy” may have resulted from the multiple catheter insertion attempts that day?

On review of the chart and following expert testimony, no deficiencies in technique could be found in the placement of the catheter. By his employment record and training, he was fully qualified to place intravenous catheters as a part of his scope of practice as a licensed nurse.

It was noted that the hospital’s standards, allowed for a maximum of two attempts before calling for assistance. The nurse in question, attempted three times.

On further review, the “community” standards, which was the measure used for this case, allowed four insertion attempts. By this standard of care, the nurse was within reasonable limits by trying three times.

Expert Testimony addressed the issue of “causation” of the patient’s “Reflex Sympathetic Dystrophy.”

In statements made, no direct causative link could be established between the starting of an intravenous catheter, and a diagnosis of Reflex Sympathetic Dystrophy.

At best, the plaintiff’s expert stated that it was a slim possibility, that a link could be made. The physician offered no support to the claim that the plaintiff’s alleged injuries were caused by the catheter insertion.

The appeals court affirmed the judgment of the lower court.

It should be noted that Intravenous Therapy, while a basic part of nursing practice, is extremely prone to complications and resulting malpractice & negligence actions.

Related clinincal Nursing (Malpractice) Case Studies:

August 8, 1999: Pregnant Prison Inmate Complains of Miscarriage, Corrections Nurse On Duty Ignores Symptoms?
Ferris v. County of Kennebec, 44 5. Supp.2d 62 –ME (1999)
Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care.
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm

August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
http://www.nursefriendly.com/nursing/clinical.cases/080199.htm

July 11, 1999: Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?
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.
Lloyd v. County of Du Page, 707 NE.2d 1252 - IL (1999)
http://www.nursefriendly.com/nursing/clinical.cases/071199.htm

June 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Official tolerance for verbal abuse and sexual harassment is approaching zero.  It is clear that both are still prevalent in healthcare settings today.  Enforcing and reporting instances of abuse are critical to an end being put to the situation.  In this case, a physician had a "history" of verbal abuse in the facility involved.  It was the documentation of previous events that made formal action and administration of a suspension feasible.
Gordon v. Lewiston Hospital, 714 A.2d 539 – PA (1998)
http://www.nursefriendly.com/nursing/clinical.cases/060699.htm

Resource Link Sections:

Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm

Courtroom Directory (National):
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms.online.htm

Direct Patient Care Links :
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Emergency Department Nursing:
http://www.nursefriendly.com/emergency/

Intravenous Therapy: Certified Registered Nurse Infusion (CRNI), Conscious Sedation, Heparin Administration, Commercial Infusion Pumps, Home Infusion, IV Fluids, Intravenous Therapy Humor, Nursing Consultants, Nursing Societies, PICC Lines, Professional Associations, Starting An Intravenous IV Line, Venepuncture, Steroid Therapy
http://www.nursefriendly.com/intravenous/

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Reflex Sympathetic Dystrophy Syndrome (RSDS), Neurological Disorders, Chronic Pain:
http://www.nursefriendly.com/rsds/

References:

1. NLRR 8 (January 2000)

2. Satarawala, Rebecca . “Confronting the Legal perils of I.V. Therapy.” Nursing2000 August 2000. Retrieved January 23rd, 2002 from the World Wide Web: http://www.springnet.com/ce/p008b.htm

3. National Institute of Neurological Disorders and Stroke, Public Domain. NINDS Reflex Sympathetic Dystrophy Syndrome Information Page. Retrieved January 23rd from the World Wide Web: http://www.ninds.nih.gov/disorders/reflex_sympathetic_dystrophy/reflex_sympathetic_dystrophy.htm