The insured in this case was a registered nurse (RN) working as a school nurse in an elementary school.
Summary
The patient was a seven-year-old first grade student. On the day of the incident, the student entered the classroom at 9 a.m. and asked the teacher for permission to go to the restroom. The student was given permission and proceeded to the restroom, where he discovered a janitor in the process of cleaning the floor. He noticed that the janitor was spraying a liquid substance on the floor and mopping the area covered by the spray. He waited for the janitor to finish and then approached the nearest urinal to void.
While he was washing his hands and preparing to return to the classroom, the student noticed that his undergarments were wet. He attempted to dry them with a paper towel and then returned to the classroom.
Shortly after the student returned to the classroom, the teacher noticed that he had his head down on his desk and appeared lethargic. After observing him for a few minutes, she asked the student if he wanted to go to the nurse. The student complained of hip pain and agreed to see the nurse. At 9:30 a.m., the teacher accompanied the student to the nurse.
The nurse greeted the student and asked him what was wrong. He told the nurse that he had left hip pain which started shortly after he used the restroom. The student denied having a fall or any other traumatic event. The nurse did not conduct a comprehensive assessment, nor did he physically examine or palpate the affected area. The school policy required the presence of two adults whenever a student needed to disrobe for a nursing assessment. That day, several staff members had called in sick, and no one was immediately available for him to call to serve as the second adult. The student’s teacher also was unavailable to assist as there was no teacher aide available to monitor her classroom at that time.
In his deposition, the nurse testified that, based upon his observations, the student’s gait was within normal limits, and he did not regard the student’s complaint as serious. Therefore, he did not pursue obtaining a staff member to witness an examination that would require disrobing.
An ice pack was provided, and the student returned to the classroom. The visit with the school nurse lasted approximately fifteen minutes.
At approximately 11 a.m., the teacher noticed that the student was becoming increasingly lethargic and continuing to complain of hip pain. She examined the student’s left hip by slightly pulling down his sweatpants and identified a wound that was actively draining fluid. The teacher immediately recognized this as a serious medical situation and carried the student directly to the health room at about 11:15 a.m.
The nurse observed a 3 cm by 3 cm wound on the student’s left hip, posterior to the iliac crest, which was surrounded by a reddish-yellow skin discoloration. He immediately contacted the student’s mother to request that she pick up the student and obtain a medical evaluation.
At 11:45 a.m., upon arrival to the school the student’s mother observed the wound with the nurse. The nurse advised the mother to take the student immediately to the nearest emergency department, and the mother agreed. This discussion was not documented in the school health record. The only documentation by the nurse was that the student was sent to the nurse for hip discomfort and was given an ice pack. In addition, the student’s underwear was wet but was not removed by the nurse or the student’s mother.
At approximately 12:21 p.m., the student arrived at the hospital emergency department (ED) and was seen by a triage nurse who placed the student in an “non-urgent" queue. Based upon the initial triage classification and the fact that the ED was extremely busy that day, the triage nurse did not examine the student’s hip.
At 2:15 p.m., the student was evaluated by the ED physician who immediately transferred him to the hospital burn unit for treatment of a full thickness chemical burn.
During the hospital admission, the student underwent five procedures, including two wound bed preparations and three grafting procedures, one of which failed due to infection. Following discharge from the hospital, there was a protracted period of home care, which included intensive wound management and physical therapy.
Although the student fully recovered from the surgeries, he suffered permanent disabilities including scarring, the inability to be in the sun without protective clothing and a lifelong restriction from engaging in contact sports. In his deposition, he testified that he always wore clothing that would conceal the scarring from the skin grafts.
Risk Management Comments
Six months after the student’s skin graft surgeries, a lawsuit was filed by the student’s parents (plaintiffs) against the school district asserting that the school was negligent in failing to conduct safety training for custodial staff regarding the use of caustic cleaning agents. Plaintiffs also named the school nurse individually, asserting that he was negligent in failing to perform a complete assessment and physical examination when the student first presented, resulting in a delay in treatment and an exacerbation of the burn injury. The hospital also was named in the lawsuit relating to the delays in assessment and diagnosis in the ED.
Notably, shortly after the student was diagnosed with a chemical burn, an investigation was conducted to determine the cause of the burn. A chemical engineer was hired by the student’s parents to evaluate the clothing that the student wore on the date of the incident. The investigation revealed that the wetness noted by the student on his clothing in the restroom was residual liquid from the caustic cleaning agent left on the floor by the janitor.
Plaintiff’s experts in school nursing opined that the nurse failed to conduct an appropriate nursing assessment when the student initially presented at 9:30 a.m. This omission represented a departure from the standard of care. The nurse expert also raised concerns regarding the lack of documentation.
Plaintiff’s experts in engineering and environmental management testified that the school district, through its employees, negligently applied an undiluted caustic substance to the bathroom floor which was absorbed into the patient’s clothing causing the resulting chemical burn.
Burn care experts testified that if the patient had been properly assessed by the school nurse, the student would have received expeditious treatment which would have limited the extent of the burn.
All of the experts, including the defense experts, agreed that, at both the school and the hospital, the severity of the burn was exacerbated by the cumulative delays in assessing the skin.
In a deposition, the burn specialist who treated the patient testified that the patient suffered a full-thickness chemical burn caused by an alkaline cleaning agent. The treating ED physician testified that he had never seen a chemical burn of this severity in his 10 years of practice.
In his deposition, the school nurse initially testified that he did not believe that the student’s presentation required a complete assessment and physical examination as he appeared to be ambulating without difficulty. However, in cross-examination, he later testified that his concern in being unable to find a staff member to witness an assessment was the primary reason he had opted not to perform an assessment.
Resolution
Based upon the decedent’s age and the sympathy factor potentially influencing a jury’s decision, this case had the potential for a high jury verdict. The parents’ testimonies also were compelling and sympathetic. The defense opined that the jury probably would believe that the nurse failed to adhere to the standard of care. Jurors’ opinions regarding whether the standard of care was met is based upon many factors, including the credibility of the witnesses and the experts’ deposition testimonies as well as the documentation. In this case, there was no nursing documentation to support the nurse’s testimony that he advised the parents to seek immediate medical attention. The nurse’s testimony stating that he did not complete an assessment due to short-staffing further complicated the defense.
Based upon the above-referenced defense challenges and diminished potential for a successful defense verdict, as well as the sympathy factor associated with the painful burn injury, multiple surgical procedures and permanent scars, a settlement was negotiated on behalf of the insured nurse during mediation.
Total Incurred: More than $135,000.
(Note: Figures represent the payments made on behalf of the insured and do not include any payments that may have been made from co-defendants.)
Risk Control Recommendations
- Know and comply with your state nursing practice act, the National Association of School Nurses (NASN) position statements and school district policies and procedures.
- Conduct comprehensive, accurate and timely assessments and physical examinations of students prior to making conclusions about the etiology of pain, and re-assess and monitor students who are awaiting parent pick-up and further clinical evaluation.
- Follow documentation standards established by professional nursing organizations such as the NASN and document all discussions with students/parents, and actions taken, including any treatment recommendations provided. Objective and concise documentation is essential for both continuity of care, as well as for the defense of a potential malpractice claim.
- Maintain competencies consistent with the needs of students and comply with evidence-based clinical practice guidelines, such as those promulgated by the NASN.
RESOURCES
Disclaimers
These case scenarios are illustrations of actual claims that were managed by the CNA insurance companies. However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. This material is for illustrative purposes and is not intended to constitute a contract. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.
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