Nurse Case Study: Improper nursing management of a home healthcare patient, resulting in multiple amputations

Nurse Professional Liability Case Study with Risk Management Strategies Presented by NSO and CNA


Our insured registered nurse (“the nurse”) was an independent contractor working for a home healthcare agency. The nurse was caring for a patient on a Friday afternoon. The patient was a 75-year-old Hispanic male who had immigrated to the United States several decades prior. The patient had a history of diabetes, dialysis, cardiac disease and was currently suffering from a stage III pressure injury to his left heel. Due to a language barrier, the patient relied on his grandchildren to translate for him during healthcare visits.
During the 4th visit, the nurse assessed the foot. The patient’s grandchildren were not at the home during this nurse’s visit to the home. The nurse had access to an interpreter language line but did not use it as she believed the patient seemed to be able to understand her. While assessing the foot, the nurse informed the patient that the wound had worsened and appeared infected. Knowing that the patient’s provider’s office was closed for the day/weekend, the nurse advised that the patient be evaluated and treated by an emergency department (ED) provider. The patient refused to go to the ED as he could not afford any more medical bills. He also reminded the nurse that he had an appointment with his provider the following Monday morning.
The following day (Saturday), the patient became feverish. Over the next twelve-hours, his physiological condition continued to decline, and he ultimately went to the ED on Sunday night.
The patient was diagnosed with sepsis. Due to his body’s response to the infection and medications to treat the sepsis; he developed gangrene to his fingers and toes, which led to multiple amputations.
The patient (plaintiff) filed the original lawsuit shortly after his hospitalization against the home healthcare agency.
The patient passed away shortly after filing the lawsuit. A new lawsuit was filed on behalf of his estate and this time it included our insured nurse. The allegations against the insured included:

  • Improper nursing management of a patient, resulting in multiple amputations;
  • Failure to monitor/report changes in the patient’s condition to the referring practitioner;
  • Failure to document significant patient information, such as nursing assessments, care implemented and potential medical interventions;
  • Failure to provide written documents in the patient’s primary language and/or failure to provide an interpreter to translate documents and important for the patient/responsible party; and
  • Failure to provide unbiased nursing care to an immigrant patient resulting in patient death.

Risk Management Comments

Defense experts were asked to review this claim and were generally supportive of the nurse’s actions. However, upon the defense’s review of the fact surrounding this case, there were several concerning factors that the defense felt could impact the insured nurse’s ability to prevail in a trial:
  • First, the insured's documentation did not support that the patient understood the gravity of her conversation with him about his wound being worse or needing emergency treatment. The plaintiff also denied these conversations occurred.
  • In addition, the patient/his wife spoke limited English, as their primary language was Spanish. The insured only speaks English. As such, there was a communication barrier between the insured and the patient, and despite having access to a language line, the nurse failed to utilize this resource.
  • During the insured’s interview with defense counsel, she relayed that she also failed to call the referring practitioner and alert him to the patient’s worsening condition. She stated that since it was a Friday afternoon, she knew the office would be closed. However, the insured acknowledged the fact that although the office was closed, there was a medical provider on-call that she could have contacted.
  • The defense counsel found that the insured had several questionable posts on her social media accounts that could lead a jury to believe she held biases against immigrants.

Due to these factors, the claim was scheduled for mediation.  


A settlement was paid on behalf of the nurse at the end of mediation, with the total amount incurred to settle and defend the case totaling over $250,000.* As mandated by state law, the nurse was also reported to the National Practitioner Data Bank (NPDB).
*Monetary amounts represent only the payment made on behalf of the insured registered nurse and does not reflect payments made on behalf of the other parties involved in the claim.

Risk Management Recommendations

  • Ensure that nursing practice is safe, effective, efficient, equitable, timely, and patient-centered.
  • Take time to consider cultural, racial, and social differences when treating patients. In addition to taking steps to address language barriers and health literacy issues with their patients, nurses must also work to recognize how individual biases and structural oppression impact clinical care. Creating an inclusive environment for patients and colleagues is critical to providing equitable, quality nursing care.
  • Acknowledge that race, racism and biases factor into healthcare. Independent research and continuing education on implicit biases and cultural competency is key to bettering yourself as a medical professional.
  • Practice with compassion and respect for the inherent dignity, worth and unique attributes of all people.
  • Act as the patient’s advocate in ensuring patient safety and the quality of care delivered.
  • Document each visit or encounter, documenting the date and time, implementation of the plan of care, changes in patient status, and progressions of specific interventions used.
  • Communicate in a timely and accurate manner both initial and ongoing findings regarding the patient’s status and response to treatment.
  • Document the practitioner notification of a change in condition/symptoms/patient concerns and document the practitioner’s response and/or orders.
  • If attempts to voice concerns regarding the patient’s status are disregarded, but the nurse believes patient safety is or may be severely compromised, then take a stronger course of action, by notifying a supervisor or invoking the chain of command policy/protocol.
  • Refrain from posting photos or comments on social media that could be considered unprofessional, such as content that includes:
    • Alcohol or drug use
    • Profane, sexually explicit, or racially derogatory comments
    • Negative comments about co-workers and employers
    • Threatening or harassing comments

  • Know and comply with your facility’s/employer’s policies, procedures and protocols.
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. Please note that Internet hyperlinks cited herein are active as of the date of publication, but may be subject to change or discontinuation. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. Use of the term “partnership” and/or “partner” should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2021 CNA. All rights reserved.

This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. This publication is published by Affinity Insurance Services, Inc., with headquarters at 1100 Virginia Drive, Suite 250, Fort Washington, PA 19034-3278. Phone: (215) 773-4600. All world rights reserved. Reproduction without permission is prohibited.
Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc. (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc. (CA 0G94493); Aon Direct Insurance Administrators and Berkely Insurance Agency; and in NY, AIS Affinity Insurance Agency.

© 2021 Affinity Insurance Services, Inc.

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