Nurse Practitioner Case Study: Failure to timely address behavioral health condition/complication

This case study involves a nurse practitioner in an office setting.

Note: There were multiple co-defendants in this claim who are not discussed in this scenario. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited to the actions of the defendant; the intensive care unit nurse.

Indemnity Settlement Payment: $0
(Monetary amounts represent only the payment made on behalf of the insured nurse practitioner)
Legal Expenses: Greater than $195,000

Our insured psychiatric nurse practitioner (defendant) had a long standing treating history (six years) with a patient (plaintiff) for the treatment of depression and attention deficit disorder.  The patient began seeing the nurse practitioner because she was having marital problems with her husband and was considering divorce.  The patient also complained about having some episodes of depression and felt she might have Seasonal Affective Disorder (SAD).  On the initial evaluation, the patient denied knowledge about a personal and/or family history of bipolar disorder, but stated she and her mother had a history of mood swings herself. Although she initially denied any history of bipolar disorder during the first five years of treatment with the nurse practitioner, the patient testified that she had very erratic behavior the entire time she was under the care of the nurse practitioner.
The nurse practitioner treated the patient for SAD for the first few months, but eventually diagnosed her with Attention Deficient Disorder (ADD) and major depression.  The patient was prescribed Wellbutrin® and Adderall, and seemed to be tolerating the medications well during the initial five years of treatment, with slight dosing changes through her pregnancies. The nurse practitioner felt that the patient’s depression had more to do with her relationship with her husband and her struggle to free herself from his manipulation.  During her visits the patient spoke openly about her financial debt related to credit card spending, but never fully disclosed the amount of debt. The patient also went through the loss of her mother to brain cancer during the years of treatment and this seemed to put the patient in a downward spiral of deep depression keeping her from maintaining employment.
At one point the patient’s husband called the nurse practitioner because his wife seemed distant; he claimed that she was not taking care of their children and had been spending money carelessly. The nurse practitioner later testified that this concerned her, but that she was unable to speak with him about his wife due to patient privacy matters. The nurse practitioner immediately contacted the patient after the phone call and the patient adamantly denied the accusations from her husband. During the patient’s next appointment, the nurse practitioner recalled going through the symptoms of bipolar disorder with the patient in conversation, but the patient denied any symptoms or thoughts of suicide.  During the final months that the nurse practitioner had contact with the patient, she was again planning on leaving her husband, which appeared to be a theme throughout the patient’s treatment. 
The patient’s husband initially filed for divorce, but prior to his filing he secretly video recorded his wife, their home and children to demonstrate how bad his wife’s behavior had gotten. After filing for divorce, he called the department of family and children services (DFACS) to report his wife’s inability to safely care for their children and reported that she was acting erratically. DFACS required the wife to have a drug evaluation and granted the husband temporary custody of the children.  The drug test showed the patient had been using marijuana and was taking illegally obtained oxycodone. The patient was extremely distressed during this period and the nurse practitioner associated her emotional state with the loss of custody of her children and potential jail time due to her failed drug test.
A few weeks later, the nurse practitioner received a letter from the husband’s attorney requesting his wife’s medical records. The nurse practitioner informed the patient of the request during one of the last visits. The patient was obviously upset and requested the nurse practitioner prepare a statement indicating that she was emotionally stable and that the husband was the reason for the patient’s erratic behavior. The nurse practitioner agreed and told the patient she would do everything she could to help the patient.
After the last visit with the nurse practitioner, the patient was self-admitted into the hospital secondary to erratic behavior. While in the hospital the patient was diagnosed with bipolar disorder. The nurse practitioner learned that the patient reconciled with her husband and was apparently doing well after her hospitalization.
One year later, the patient filed a lawsuit against our insured nurse practitioner for failure to diagnose bipolar disorder, alleging that this delay in diagnosis caused the plaintiff to engage in excessive spending and inappropriate behaviors such as extramarital affairs, and resulted in her losing her employment. 
The plaintiff claimed damages of:

  • Medical expenses: Greater than $20,000
  • Lost wages: Greater than $110,000
  • Future wage loss: Greater than $500,000
  • Non-economic damages: Greater than $200,000
Risk Management Comments
Defense experts supported the care and treatment our insured nurse practitioner provided to the plaintiff.  The only concern was that the plaintiff’s family was sympathetic, and defense counsel was concerned that a jury could look past our viable defenses and award damages. 
The nurse practitioner made a fair witness during her deposition testimony. When she was questioned about her medical documentation, she was adamant that she would take handwritten notes in a “notebook” during her treatment sessions and later transfer her notes electronically because her hand writing was hard to read.
Due to this concern, and at the strong request of the nurse practitioner, we engaged in settlement discussions in an attempt to resolve the matter for a compromised amount, but despite great effort the case went to trial.
During the trial, our insured nurse practitioner testified that the patient’s medical record was not the original. The nurse practitioner testified that she had manipulated the patient’s chart when she received a records request from the patient’s spouse’s divorce attorney.  The nurse practitioner admitted in open court that she had altered the medical record to delete information that could be damaging to the plaintiff.  This was information that had not previously been disclosed to the defense counsel, and was potentially damaging to our defense.
The jury deliberated for four hours, and despite the nurse practitioner’s damaging testimony regarding the patient’s medical record, the jury found in favor of the nurse practitioner. 
We believe the primary reason the jury found in favor of the nurse practitioner is that both the plaintiff and her spouse were not compelling witnesses and attempted to inflate their damages. If the plaintiff had been credible, chances of a plaintiff verdict and sizeable award were likely in light of the nurse practitioner’s damaging testimony regarding charting practices.
Risk Management Recommendations
  • Document in the medical record contemporaneously, factually and thoroughly. The medical record should never be altered or destroyed.
  • Refrain from subjective comments, including statements about patient, family or other members of the healthcare team. 
  • Educate each patient regarding the steps involved in the treatment process, as well as the patient’s responsibility to notify the practitioner of any condition, unusual occurrences or feelings of distress during the treatment.
  • Ascertain the patient’s level of compliance with currently ordered treatment and care instructions, medication regimens and lifestyle suggestions.

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