COURT CASES RE: DOCUMENTATION

CASE # 1

PT, POST-CVA, POST CABG, WITH PEG TUBE 70 y/o male suffered CVA post- CABG, resulting in need for permanent PEG (percutaneous endoscopic gastrostomy) tube for feedings.

PT, POST-CVA, POST CABG, WITH PEG TUBE Standard of care for such a pt calls for the feeding tube to be checked for residual feeding formula and flushed every four hours.

PT, POST-CVA, POST CABG, WITH PEG TUBE On 3 consecutive days the nurses documented that tube feeding had to be turned off for short periods because residual formula aspirated from the stomach exceeded the normal limit.

PT, POST-CVA, POST CABG, WITH PEG TUBE Pt’s condition stabilized and he was moved to a transitional care unit, with admission orders of: 65 mL/hr by PEG tube, keeping degrees at all times, and recording VS q6h.

PT, POST-CVA, POST CABG, WITH PEG TUBE When the pt was transferred to transitional care unit, a nursing admission form was completed, but no vital signs or assessment of the tube feeding were recorded.

PT, POST-CVA, POST CABG, WITH PEG TUBE Nursing notes stated that at 2200 the HOB was elevated to 45 degrees and that formula was infusing through PEG at 55mL/hr.

PT, POST-CVA, POST CABG, WITH PEG TUBE There was no documentation of checking for residual formula and patency of the tube, calls to the physician, or new orders for a different infusion rate, nor an explanation of different infusion rate than ordered.

PT, POST-CVA, POST CABG, WITH PEG TUBE Nursing staff documented that at 0100 they heard the patient coughing. Pt was ashen and had vomit on his face; he had aspirated the formula.

PT, POST-CVA, POST CABG, WITH PEG TUBE Although the pt was transferred to the ICU and intubated, the pt died later that morning as a result of aspiration pneumonia.

PT, POST-CVA, POST CABG, WITH PEG TUBE Pt’s family filed a negligence claim against the hospital and members of the nursing staff.

PT, POST-CVA, POST CABG, WITH PEG TUBE There was no documentation to show that the nursing standards of care for assessment, planning, implementation, and evaluation had been met.

PT, POST-CVA, POST CABG, WITH PEG TUBE The hospital and the pt’s family agreed to a confidential settlement.

LESSONS LEARNED When a nurse is accused of negligence, ignorance of the standards of nursing care does not serve as a viable legal defense.

LESSONS LEARNED “The RN attains knowledge and competency that reflects current nursing practice.” ANA Standards of Professional Performance

LESSONS LEARNED If there’s no documentation, there is no evidence.

LESSONS LEARNED Jurors cannot assume that a patient received care if a nurse failed to document it.

LESSONS LEARNED If a patient experiences an adverse event, such as a fall, the standards of care require the nurse to document the pt’s condition before and immediately after the incident, as well as the time the physician was notified.

LESSONS LEARNED The documentation must also include the physician’s response and any new orders.

LESSONS LEARNED The nursing response to an adverse event must also be documented in the pt’s record.

CASE # 2