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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.
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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 ptcalls 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 HOB @ 30-45 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.
