Nurse Practitioner Case Study: Failure to ensure that essential monitoring of vital signs, fluid intake and urine output were performed and documented

The patient was a 59-year old female who had undergone inpatient bilateral salpingo-oophorectomy three days before being discharged to home care. Discharge orders included a home care referral for wound care and assessment of perceived changes in the patient’s mental status. 

The nurse practitioner was a contracted staff member of the home care agency that was providing the patient’s home care. The nurse practitioner was assigned to assess and manage the patient’s home care and to supervise the daily nursing and wound care provided by the agency’s licensed nurses. 

The patient’s subsequent wound infection was managed by the surgeon who ordered wound care that he identified as “an old-fashioned wound remedy”, which involved placing honey into the wound. This was not a treatment known to the nurse practitioner. Documentation regarding evidence of infection, wound appearance, wound size, drainage amount and appearance is inconsistent among the nurses caring for the patient. Temperatures were taken regularly, but the patient’s blood pressure was not recorded until day fourteen of home care when the vital signs were 124/58, 80, 16 and 97.8. The next day, the vital signs were 112/64, 88, 16 and 98.3.
On day sixteen, the nurse practitioner saw the patient and was informed that she had fallen twice during the night. She complained of increased weakness, fatigue, and tingling pain in her hands. Her tongue was noted to be covered with white plaque. Vital signs were 102/54, 100, 18 and 95. The patient was scheduled to see her surgeon the following day. Despite multiple falls, vital sign changes and evidence of dehydration, the nurse practitioner did not recommend or initiate emergency care and did not notify the surgeon of the falls or the other changes in the patient’s condition.
On day seventeen, the patient’s family notified the home care agency the patient had fallen in the shower and was unable to get up, 911 was called and despite emergency intubation and cardiopulmonary resuscitation efforts, she died.
Do you think this nurse practitioner was negligent?
Do you think any other practitioners were negligent?
Do you think indemnity and/or expense payment was made on behalf of the nurse practitioner? If yes, how much?
The Outcome

  • The nurse practitioner was deemed negligent in the following areas:
    • Failure to ensure that essential monitoring of vital signs, fluid intake and urine output were performed and documented
    • Failure to appreciate the plaintiff’s deteriorating condition as medically urgent and failure to report the changes in her condition to her physician
    • Failure to perform the originally ordered assessment of changes in the plaintiff’s mental status and failure to obtain a psychiatric consultation
    • Failure to appreciate the plaintiff’s increasing complaints of weakness, fatigue and anxiety as sufficiently significant to warrant additional investigation or discussion with the plaintiff’s surgeon
  • Indemnity payment – High six figures
  • Expense payment – Low five figures
Payments made on behalf of co-defendants are not available.

Risk Management Recommendations
  • Regularly assess the patients physical and mental condition and obtain appropriate objective tests and consultations to investigate the cause(s) of signs and symptoms.
  • Acknowledge, investigate and address patient complaints and document objective findings, actions taken and the patient’s response.
  • Communicate changes in the patients condition and any lack of positive response to ordered treatment to the patient’s physician and other members of the patient care team.
  • Verify that existing physician orders are carried out or clearly note the clinical reason for not carrying out such orders following consultation with the ordering physician.
  • Supervise the direct care nursing staff, monitor the care provided and intervene when care is inadequate, inconsistent or does not comply with physician and nurse practitioner orders.
    • Ensure that proper monitoring of the patient’s vital signs and other indicators of the patient’s condition are performed and documented.
    • Require that inconsistent and adverse findings are addressed, documented, and that the patient’s physician is notified.
  • Discuss and document unconventional or unusual treatment ordered by the physician. Obtain additional information to understand the clinical justification for such orders. If indicated, utilize the home care agency chain of command to obtain an additional clinical opinion.

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