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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/
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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 Monday, February 28, 2011
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