Question

On the afternoon of May 20, the patient, Mr. Ard, began feeling nauseated. He was in pain and had shortness of breath. Althoughhis wife rang the call bell several times, it was not until sometime later that evening that someone responded and gave Ard medicationfor the nausea. The nausea continued to worsen. Mrs. Ard then noticed that her husband was having difficulty breathing. He wasreeling from side to side in bed. Believing that her husband was dying, she continued to call for help. She estimated that she rang thecall bell for 1.25 hours before anyone responded. A code was eventually called. Unfortunately, Mr. Ard did not survive the code. Therewas no documentation in the medical records for May 20, between 5:30 PM and 6:45 PM, that would indicate that any nurse orphysician checked on Ard’s condition. This finding collaborated Mrs. Ard’s testimony regarding this time period.

A wrongful death action was brought against the hospital, and the district court granted judgment for Mrs. Ard. The hospital appealed.

Ms. Krebs, an expert in general nursing, stated that it should have been obvious to the nurses from the physicians’ progress notes thatthe patient was a high risk for aspiration. This problem was never addressed in the nurses’ care plan or in the nurses’ notes.

On May 20, Ard’s assigned nurse was Ms. Florscheim. Krebs stated that Florscheim did not perform a full assessment of the patient’srespiratory and lung status. There was nothing in the record indicating that she completed such an evaluation after he vomited. Krebsalso testified that a nurse did not conduct a swallowing assessment at any time. Although Florscheim testified that she checked on thepatient around 6:00 PM on May 20, there was no documentation in the medical record. Ms. Farris, an expert witness for the defense,testified on cross-examination that if a patient was in the type of distress described by Mrs. Ard and no nurse checked on him for 1.25hours, that would fall below the expected standard of care.

• What happened?
• Why did things go wrong?
• What were the relevant legal issues?
• How could the event have been prevented?
• What is your verdict?

Answer 1

1) What happened?

• There was a failure to communicate and a failure to supervise the patient.
• Nursing documentation has been stigmatized as burdensome, excessive and of little use or interest to others.
• It is not surprising that practicing RNs view documentation as a low priority.
• In this case, there was very little documentation of the patient's condition and the rounds that needed to be made to ensure that he was getting the medical attention that he needed.
• It would seem to me that if a patient, who has his attention bell ringing for more than half an hour, someone would have heard it.
• As outcome based measures of performance become increasingly adopted in healthcare, accurate and comprehensive  documentation of nursing practice must be essential to maintaining and increasing nursing's influences within institutions and in health policy decisions.
• Nurses need to resist the elimination of comprehensive nursing documentation for a short term gain, but a long term loss.
• Documentation is a critical component of nursing practice, not an afterthought.

2) Why did things go wrong?

• Things might have gone wrong because there may have been an omission in the patient's health care plan of him being a high risk patient.
• If, he was high risk he should have been in a high risk area.
• There are potential legal risks to the exclusion of documentation or the adoption of new documentation methods.
• Again, the comprehensiveness of nursing documentation and it relevance to the client's health are critical.
• None of these areas were seen as a priority in this case.
• With the emergence of methods such as "charting by exception" nurses face increased risk of not having the evidence they might need to defend themselves in the event of legal actions, as in this case.

3) What were the relevant legal issues?

• Whenever, a practitioner fails to make use of available information in the case of Mr. Ard, there is a very high risk of being sued. This especially true when making practice decisions. For example, if nursing decision- supports are available, and a nurse does not use it, and an incorrect diagnosis or intervention plan is made, there is potential liability. When there is access to scientific knowledge bases that would improve the accuracy of the practitioner's clinical decisions and the nurse does not access those knowledge bases, there is greater legal risk in the event of an incorrect and harmful decision. All of these issues were disregarded and in our opinion helped to cause his death.
• The assigned nurse Ms.Florscheim who did not perform a full assessment of Mr. Ard's status after he vomited. This action was in direct violation of nurse's policies and procedures.
• A test to determine if the patient could swallow was not done and documentation was done to rule out this as being a concern. Proper care was not a concern in this case. There is an expectation of standard care whenever patients are in the care and custody of professionals.

4) How could the event have been prevented?

Yes, there is no doubt that the patient could have been given better care. If,he could have lived out the night is another question. Was it his time to leave this world and would he have died of something else? We will never know. But, what we do know is that he did not get the care that he needed.

5) What is your verdict?

The court was right to find in favor of Mrs. Ard.