Nurse Case Study: Failure to follow policies and procedures on skin integrity

This case study involves registered nurse working in an operating room setting and adult surgical unit.

Indemnity Settlement Payment: Greater than $116,000
(Monetary amounts represent only the payment made on behalf of the insured nurse practitioner)
Legal Expenses: More than $87,000

(Monetary amounts represent only the payments made on behalf of the insured registered nurse and does not reflect payments made on behalf of any other parties involved in the claim.)
A 65 year-old female patient was taken to the emergency department (ED) after suffering a fall at home. Her husband had been away from the house several hours and when he returned home he found her on the floor. The patient was confused and no one was able to ascertain how long she had been lying on the floor.
She was taken to the nearest emergency department with complaints of weakness, confusion and right lower leg and foot pain. Her past medical history included Parkinson's disease, mild dementia, hypothyroidism and anxiety.
The radiology results revealed an open displaced fracture of the right tibia and fibula. An orthopedic surgeon requested the patient be prepped for surgery. However, there was over a four hour delay getting the patient to surgery for various reasons.
The patient underwent an intramedullary (IM) nailing procedure which lasted approximately three hours. After the procedure, the patient was admitted to the orthopedic floor with orders to follow the post IM nailing procedure standing protocol. In the intraoperative nursing (pre-operative and post-operative) assessment, documentation regarding skin integrity was incomplete as well as documentation of the position aides.
The patient was taken to the surgical floor with orders to be placed on the post IM nailing surgery protocol. The protocol included comprehensive orders for vital signs, pain control, nutrition, hydration, mobilization and skin integrity prevention measures. The admitting nurse assessed the patient’s skin and gave her a risk score of 14 according to the Braden Scale® (the lower the number, the higher the risk to develop pressure ulcer). The hospital’s “Alteration in Skin Integrity” protocol required an air mattress for any patient with a score of less than 18.
Although the admitting nurse ordered medical air mattress overlay for the patient, the hospital did not have any available. A request for a mattress was placed with an outside vendor, but since it was a holiday weekend the delivery of the mattress would take at least eight hours. The following day (post-operative day one), the day shift nurse assessed the patient and documented a skin assessment score of 20.
Skin assessments and repositioning documentation were missing on several shifts, despite hospital policy. Skin checks are required once a shift and skin integrity protocols require repositioning a patient every two hours.
On post-operative day three, the night shift nurse reported the presence of a purple localized area of discolored intact skin on the patient’s sacrum. However, it wasn’t until the night nurse returned that the patient was finally placed on an air mattress. On post-operative day five, the patient was discharged to a local skilled nursing facility. The patient’s admitting diagnosis to the skilled facility was status-post IM nailing, Parkinson's disease, mild dementia, hypothyroidism, anxiety, anemia and Stage IV decubitus ulcer.
Over the next nine months the patient suffered from infections, debridements and anemia all related to the sacral ulcer. At one point the size of the ulcer was 8.5 cm in length, 7cm in width and 4 cm in diameter. To prevent further infections the patient underwent a sigmoid loop colostomy, a sacral osteotomy and a second bilateral gluteal flap repair for the non-healing ulcer. A urinary catheter was used to prevent further skin breakdown and since the patient struggled with malnutrition due to infection, a gastrostomy tube was inserted during one of her hospitalizations. 
The patient died 10 months after her fall. The family (plaintiff) of the deceased filed a malpractice claim against the hospital and seven registered nurses (individually) involved in the patient’s care related to her hip surgery.
Five of the seven nurses were NSO/CNA insureds. The five nurses included:

  • The circulating nurse (assisting the orthopedic surgeon during the right IM nailing)
  • The registered nurse first assist (assisting the orthopedic surgeon during the right IM nailing)
  • The day shift nurse (post-operative days one and two)
  • The day shift nurse (post-operative days three and four)
  • The night shift nurse (post-operative days one and two)
The plaintiff opined that the staff, management, and owners of hospital provided care to the patient that fell below the accepted standards of care, which included:
  • The operating room skin assessments were incomplete as well as any documentation of the position aides.
  • The hospital’s Alteration in Skin Integrity Protocol was not implemented after surgery.
  • The nursing assessment flow sheets, a specialty bed/mattress was ordered but not provided to the patient until the breakdown was at Stage 4.
  • The surgical unit nurses failed to turn and reposition every two hours throughout the patient’s hospitalization.
Risk Management Comments
Two of the insured nurses were dismissed early in the case. However, the circulating nurse, registered nurse first assist and the day shift nurse (post-operative days one and two) remained in the case and a payment was made on their behalf.
Defense experts explained that the ulcer was initiated by the patient laying on a hard surface, such as a floor or ambulance backboard. The remaining three nurses’ documentation was poor. They also appeared very defensive and arrogant during their depositions. 
Defense counsel was afraid that their appearance would anger a jury if this case went to trial. Despite excellent defense expert opinions on the cause of the ulcer, the professional liability claims against them were difficult to defend.
Risk Management Recommendations
  • Follow documentation standards established by professional nursing organizations and comply with your employer’s standards.
  • Develop, maintain and practice professional written and spoken skills.
  • Ensure that communication among caregivers and between caregivers and patients, is inclusive.
  • Carefully communicate patient assessments and observations to other members of the healthcare team, in order to develop and modify the pain of treatment and care as necessary.
  • Know your organizations policies and procedures related to clinical practices and documentation.
  • Practice ongoing patient assessment and monitoring.
  • The healthcare team relies upon nurses to communicate in a timely and accurate manner both initial and ongoing findings regarding patient status and responses to treatment.


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