Nurse Practitioner Case Study: Failure to monitor patient receiving testosterone injections

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

Case Study: Failure to monitor; failure to complete documentation in a timely manner; failure to identify and address concerns or questions regarding patient care; failure to follow the standard of care.

Indemnity Settlement Payment: Greater than $500,000
(Monetary amounts represent only the payment made on behalf of the insured nurse practitioner)
Legal Expenses: Greater than $120,000

The patient (plaintiff) in this case was a 50 year-old male who first came to our insured nurse practitioner after researching his symptoms on the internet. He self-diagnosed his symptoms as possible adrenal fatigue. His previous history included an appendectomy, vasectomy, blood transfusion following a colon resection due to emergent gallbladder surgery.
During the initial assessment the patient recalled being exhausted since having two bowel perforations were he claimed to have almost died. Further, he claimed to have been to over 20 doctors and no one was able determine what was making him tired. The NP documented his symptoms which included fatigue, night sweats, unintentional weight loss, headaches, temperature intolerances, excessive thirst and sleep disturbances. He reported his social history as a nonsmoker, occasionally used alcohol and was employed as a long-tour bus driver and was expected to drive for several hours a day.
The insured ordered a general health panel along with a PSA level and instructed the patient to return in two-weeks for a follow-up visit. The general health panel was unremarkable, but a few outliers showed that patient’s testosterone was 224 ng/dl (expected 241-827), calculated free testosterone was 4.6 ng/dl (expected 6-27), and his PSA was 9.4 ng/dl (expected < 4.0).
At the follow-up appointment, the insured informed the patient about his elevated PSA level and discussed the potential false positives with PSA levels. She ordered a PSA level be redrawn and a urine sample. The results of the redrawn lab showed that patient’s PSA level remained abnormally high at 9.3 ng/dl and a normal urine specimen result.
The plan was to have the patient follow up with a urologist and an appointment was made with one four days later. According to the urologist, the patient’s problems included elevated PSA (9.4), testicular pain, generalized weakness, fatigue and perineal pain. He was noted to have an "intense medical history for the past three years”. During his examination, the urologist noted the patient to have a normal phallus with descended testes. His perineal area was tender, but no masses were felt. His prostate was slightly enlarged and his left lobe was indurated and tender.  Furthermore, the urologist noted "extensive blood work ok” and diagnosed the patient with: generalized weakness, fatigue, elevated PSA x2 in range of 9, symptoms consistent with prostatitis and hypogonadism.
The plan was to give the patient a 200mg testosterone injection, Cipro 500mg BID for 15 days, to have another testosterone shot in two to three weeks, re-check his PSA in two-weeks and return to the office for a follow-up a few days after the PSA level is obtained.
The urologist’s records indicated that the patient was a "no show for the repeat PSA and office visit”. The chart stated that the patient apparently reported that he was "doing so much better" and was reason for his “no show”.
A few weeks after the urologist visit, patient called the insured’s office to say he had seen the urologist and was diagnosed and treated for prostatitis. He was given a testosterone injection and was due another one, but wanted the insured to “manage his testosterone injections and let the urologist mange his prostatitis because he felt the insured was more knowledgeable with hormone replacements than the urologist”.
Over the next 11 months, the patient received 200 mg of testosterone injections every two weeks.  He only saw the insured once during that time and this appointment was scheduled due to finding blood in his urine during a DOT physical.  During that visit, he stated that for the past month he had suffered low back pain, painful urination and low grade fever. He was worried that it might be prostatitis again and the insured agreed with him and suggested that he follow-up with his urologist.
Prior to the patient leaving the office, she scheduled an appointment with the urologist that he had previously seen. The patient never showed up for his scheduled appointment, but instead made an appointment with second urologist.
The patient listed his chief complaint as “prostatitis”. The urology healthcare record reported that the patient stated his PSA level was “OK 1-year ago”. The urologist’s impression was prostatitis, benign prostatic hyperplasia and low testosterone. The plan listed was “Cipro 500mg BID for 15 days, patient can’t afford CT scan and deferred any follow at this time”.
The patient never came back to the insured, but eventually sought treatment from a third urologist seven-months later for recurring low back pain, painful urination and low grade fever.
While at the urologist, the patient had his PSA level checked and it tested at 10.5 ng/ml. The urologist took a biopsy and diagnosed the patient with prostate cancer. The tumor stage was T4a without metastatic disease.
The patient filed a lawsuit against multiple healthcare professionals, including our insured nurse practitioner. The patient alleged that the nurse practitioner:

  • Failed to appropriately monitor PSA levels upon initiating and treating him for months with testosterone therapy.
  • Breached the standard of care when the insured did not order or discuss with the patient the importance of having additional PSA tests performed while receiving numerous testosterone injections.
During the patient’s deposition, the patient stated that the reason he wanted the insured to manage his testosterone injections was that he had a delinquent balance with the first and second urologists and didn’t want to go back to those offices.
Risk Management Comments
The primary problem in this case is the inescapable fact that the patient continued to receive testosterone injections ordered by the insured for eleven (11) months without any monitoring or laboratory to follow his PSA level to ascertain whether it was rising.
Experts stated that review of literature would indicated that the standard of care generally requires that PSA levels be obtained bi-annually during testosterone therapy such as ordered and managed by the insured. However, the insured didn’t have an explanation for not ordering a PSA other than believing that the patient’s urologist was following his PSA.
The insured’s documentation is somewhat vague regarding communication with the patient and her recollection that the PSA levels were to be followed by the urologist to whom she referred him is not documented at all.
The experts were critical that the insured never communicated directly with his urologist(s), requested any laboratory findings from his urologist(s) or even asked the patient for the results of his PSA. Had she done so, it would have become apparent that the patient was not being followed by a urologist.
Given the negative expert opinions, the decision was made to attempt to settle the claim on behalf of the nurse practitioner.
Risk Management Recommendations:
  • Follow documentation standards established by professional organizations and comply with your employer’s standards.
  • Document all patient-related discussions, consultations, clinical information, actions taken including any treatment orders provided and decision making process.
  • Engage in timely and proactive discussions with providers of the patient’s treating team and assure they are educated about the patient’s treatment plan.
  • Review the recommended care plan with patients and confirm that they agree to the plan and understand their responsibilities.
  • Discuss possible barriers to compliance with treatment recommendations.
  • Document all efforts made to communicate the need for compliance in the healthcare record.
  • Provide a written description of the potential harmful consequences of noncompliance. Request that patients sign the document, then give them a copy of it and place the original in the patient healthcare information record.
  • Assess the risk involved in continuing to provide care to chronically noncompliant patients. In some cases, it may be necessary to suspend or terminate the physician-patient relationship.
  • If patients are noncompliant due to financial reasons, refer them to the appropriate agencies (manufacturer drug-provision programs, federal programs) for assistance.

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