The case of a pediatric patient at a walk-in clinic with leg laceration and subsequent infection.

The pediatric patient was a 12-year-old male brought into a walk-in clinic by his parents shortly after falling and lacerating his knee. The patient sustained a six centimeter elliptical laceration above his right knee.

Case Study: Failure to identify and address concerns or questions regarding patient care; failure to complete documentation in a timely manner; failure to act as the patient’s advocate; failure to maintain clinical competencies; failure to follow the standard of care
 
Indemnity Settlement Payment: Policy limits.
(Monetary amounts represent only the payment made on behalf of the insured nurse practitioner)
 
Legal Expenses: In excess of $230,000
 
The pediatric patient was a 12-year-old male brought into a walk-in clinic by his parents shortly after falling and lacerating his knee. The patient sustained a six centimeter elliptical laceration above his right knee.
 
The patient was examined by the nurse practitioner who documented a normal physical examination, except for evidence of a six centimeter elliptical laceration. The nurse practitioner cleansed the site with Betadine, anesthetized the area and sutured the wound using nylon sutures.
 
The patient was discharged with a prescription for acetaminophen with codeine and a prescription for augmentin, although the healthcare information record stated he was allergic to penicillin.
 
The nurse practitioner did not counsel the parents on dressing or wound care at discharge, but communicated to follow up in 7-10 days for suture removal.
 
The mother filled the antibiotic prescription, but only gave the child one dose after she noticed that a skin rash was resulting.  Later, she testified in her deposition that she neither called the walk-in clinic nor the nurse practitioner about a new antibiotic for the child.
 
Two days after the fall, he was admitted to the local hospital with a diagnosis of cellulitis, possibly due to methicillin resistant staphlococcus aureus (MRSA) and was given intravenous antibiotics.
 
Three days after the fall, his right extremity appeared edematous, slightly discolored and he complained of pain with movement. He was taken to surgery with a diagnosis of an abscess of the right thigh. During the operation, the sutures were removed with serosanguinous drainage noted. The tissue surrounding the wound appeared gray and discolored.
 
Four days after the fall, his extremity appeared completely discolored, severely edematous, and he had very limited movement. He was taken back to surgery for a re-exploration, further debridement and insertion of a central venous catheter.                                                                  
 
After the re-exploration, the patient was transferred to a children’s hospital several miles away via helicopter for further treatment and observation. While in the children’s hospital, the patient underwent multiple fasciotomies and surgeries to repair and re-route muscles, tendons and ligaments to his extremity and sacral area due to the advancing necrotizing fasciitis.
 
His condition continued to deteriorate, resulting in a comatose state responding only to painful stimuli. While in this comatose state, he was noted to have recurrent uncontrolled seizures.
 
The patient slowly recovered. Six weeks after the injury occurred, he was discharged from the hospital with home health and wound care services. Following discharge, the child had to re-learn simple activities of daily living, e.g., walking, running and bathing.
 
Due to the seizures and coma, the child has encountered problems with emotional and intellectual development. The bacterial infection and subsequent treatment impaired movement with his right leg, requiring several skin graphs and physical therapy.
 
Risk Management Comments
There was no documentation on wound irrigations or discharge teaching.  When the nurse practitioner learned of the patient’s hospital admission, she documented a self-serving addendum to the clinic’s healthcare information record.
 
None of the defense expert reviewers fully supported the nurse practitioner’s care. It was determined that she failed to prescribe the appropriate antibiotic, failed to appropriately suture the wound and failed to irrigate the wound as standard protocol would require.
 
Experts were also critical of the suturing technique that the defendant used.  Their testimony noted that the sutures were too tight, creating an anaerobic environment which contributed to the growth of the necrotizing fasciitis.
 
Resolution
Given the negative expert opinions, the decision was made to attempt to settle the claim on behalf of the nurse practitioner.
 
Risk Management Recommendations
  • Prescribe the right drug, for the right patient, in the right dosage, the right route, at the right times, for the right duration and for the right indication.
  • Identify and address concerns or questions regarding patient care treatments and ensure that any concerns are resolved prior to discharge.
  • Document all patient-related discussions, consultations, clinical information and actions taken, including any treatment orders provided and ensure that the documentation is timely.
  • Complete documentation in a timely manner. If an addendum to the healthcare information record is needed, avoid documenting in a manner that is self-serving and state information factually.
  • Report and act upon any adverse patient event or response to treatment and pursue the matter through the organization’s clinical and/or administrative chain of command until appropriate resolution.
  • Act as the patient’s advocate in ensuring patient safety and the quality of care received.
  • Assist the patient and/or authorized family members in communicating with the treatment team.

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