Alleged Failure to Monitor and Report Changes

This case study involves a registered nurse with 19 years’ experience as an emergency nurse (15 as a certified emergency nurse) was working in the triage area of the emergency department.

A 34-year-old female patient was sent to the emergency department from the local dialysis clinic to have her hemodialysis catheter, which was bleeding around the insertion area, examined by the emergency department practitioner. The patient was accompanied by her mother and son, who appeared to be about 10 years old. The insured nurse, who was working in the triage area of the ED, noted in the triage portion of the medical record that the patient appeared ill and disheveled, and she allowed her mother to answer all the medical questions.

During the 15-minute triage process, the nurse noted that the patient’s vital signs were normal, she had plus two pitting edemas in her lower extremities and her catheter seemed intact with a small amount of dried blood, but no active bleeding at the insertion site. On a five-level emergency department triage scale, the nurse rated the patient as a “3-urgent,” meaning that the patient should be seen by a practitioner within 15 to 60 minutes following triage, per facility policy. As there were no available beds in the treatment area of the emergency department, the nurse asked the patient and her family to take a seat near the triage area to facilitate monitoring.   

Shortly after our nurse performed the triage on the patient, she was relieved for her lunch break. She gave a report to the new nurse on all the patients in the waiting area, letting him know that the last patient she triaged should be the next patient to be taken to an available treatment bed. Thirty minutes later, our nurse arrived back to triage and noticed that the patient was still in the waiting area. The nurse re-evaluated the patient per hospital protocol, noting that the patient’s status remained unchanged.

Ninety minutes after the patient’s initial triage, she was taken to the emergency department treatment area. Our nurse had no additional contact with the patient. The patient was examined by the emergency department practitioner and had sutures placed around the catheter site. When the physician examined the patient, he ordered a complete blood count and a basic metabolic profile, but for reason unknown the tests were cancelled. The patient was discharged home moments after the sutures were completed and told to follow-up with the dialysis clinic the following day.

The next morning, the patient was found unresponsive and pronounced dead. An autopsy determined the cause of death to be a hyperkalemia. 

The plaintiff’s case

The mother of the patient filed a lawsuit against our nurse and many healthcare providers associated with her daughter’s care. Plaintiff experts claimed that our nurse failed to triage the patient as emergent and failed to invoke the facility’s medical chain of command when the patient was not examined by a physician within the facility set time frame. Their third claim against our nurse was that a more thorough history should have been taken and the nurse should have confirmed those laboratory tests were performed to determine the patient’s metabolic state.

Defense expert assessment

Defense experts retained determined that our nurse had acted within her scope of practice and in compliance with both the standard of care and hospital policy. 

Documentation supported the nurse’s frequent checks of the patient and the reasons for not triaging the patient at a higher acuity level.  

A successful defense

The case against the nurse was successfully defended at trial, with the jury determining our nurse was not responsible for the patient’s untimely death.

The claim took four years to resolve and over $165,000 in expenses. While it might have been less expensive to settle the claim, the nurse’s proper care of the patient and complete documentation made an aggressive defense possible which was ultimately successful. 

Risk Control Recommendations for Nurses

  • Know the Nurse Practice Act and read it at least annually to ensure you understand the legal scope of practice in your state.
  • Maintain competencies (including experience, training, and skills) consistent with the needs of assigned patients and/or patient care units.
  • Maintain a thorough, accurate and timely patient assessment and monitoring, which are core nursing functions.
  • Communicate in a timely and accurate manner both initial and ongoing findings regarding the patient’s status and response to treatment.
  • Document findings contemporaneously in the health record. Try not to make late entries unless it is appropriately labeled and is necessary for a safe continued patient care. 

#Best Practices #Case Study #Charting #ER #Nurses

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