This article describes a situation encountered while working in a remote native community in northern Canada. You never know when you may be called to court to answer why you treated a client in a particular manner. It may be up to a year after the incident when your case reaches its court date. Don't forget that, 'if you didn't chart it, you didn't do it!
While working for Health & Welfare Canada as a community health nurse, I received advanced training for outpost nursing at Dalhousie University in Halifax, Nova Scotia. In our training, we were taught the cardinal signs for assessing each body system as well as how to treat emergency cases such as pneumothorax, childbirth, intussusception, etc. This allowed us to communicate with doctors in 'their language' to describe client conditions and receive direction for treatment. The Northern native communities I have worked in receive a doctor's visit one day every six months. The doctor sees the clients that the nurse's cannot diagnose. As a nurse in one of these communities you assess, diagnose, and treat the client. I was 'on call' one evening when a young mother brought in her infant.
I pulled the patient chart and noted the infant had been seen the night before and was put on antibiotics. The client was lying in his mother's arms, he looked to be 3-4 months old and was very lethargic. I asked the mother how he was eating, and she replied that he had only had approximately 5 ounces of formula that day. I then asked what she was feeding him, thinking it would be enfalac, similac or some other acceptable commercial infant formula. When the mother answered 'coffee mate', I felt my stomach drop (listen to your gut instinct). I opened the lid, and when I put my nose to the bottle, I retched - it was putrid smelling. I instinctively tried to feed the infant electrolyte water in hopes he would receive some nutrients, but he had no energy to drink.
Failure to Thrive
I asked how old the baby was and her answer caused an uneasy feeling in my chest. I was shocked when she replied that he was a 'year old'. I plotted his height and weight on the growth and development chart to see where he was on the chart. The results showed 'failure to thrive' and this is considered very significant and warrants further medical investigation. I informed the mother that I wanted to send her son to the hospital in the city to get checked by a doctor. I had her go home and pack while I arranged a plane to transfer them. I kept the child at the nursing station because the mother voiced she didn't want to go to the city and this child needed further medical attention. I had to ensure they would get on the plane. I drove them to the airstrip and gave the medic on the air ambulance a report, the reason for the transfer and the paperwork. I was relieved when they were on the plane and transported to the hospital. I had heard that he was admitted to the hospital with a severe electrolyte imbalance and that was the last I had heard of the situation.
Investigation
About six months after the incident I was informed that there was an investigation into the case and that I was scheduled for an interview with an officer. The entire interview was taped. They wanted to get my perspective on what happened that day the infant was brought into the nursing station (this was very stressful).
Court
Months later I received a subpoena to appear in court as the infant had died. I had to get time off work, fly to the city where the case was being tried, and appear in front of the judge. It was hard to remember all the particulars of that day. By the time I was called to the stand, it was over a year from the date of the incident.
I was thankful they allowed me to look at my documentation to refresh my memory. The notes were all blacked out except my entries so I could not read what others had written. My documentation allowed me to remember the situation and the actions I had taken that day. I 'swore in' on the bible and then the questions started about why I sent the infant while the nurse the night before had not? I replied that I was not sure why the nurse or the doctor that was following this child made the decisions that they did. I can only answer for myself and that the child was diagnosed as 'failure to thrive', he was lethargic and being fed an inappropriate diet.
Lessons Learned
This infant died from severe electrolyte imbalance which could have been prevented if the infant was provided proper nutrition. Without the proper documentation of your assessment and the interventions you provided, you may be in a situation where your licence is on the line (if you didn't chart it, you didn't do it). You are accountable for your nursing decisions, actions, and documentation. Documentation provides communication between healthcare professionals to ensure everyone is aware of the client's condition and the actions taken to ensure safe care.
And, what happens when an RN DOESN'T document what she's done, the final records prove she did NOT document...and, the DON admits the RN didn't document it? The DON exact words: "It's just that it didn't get documented! We've discussed it with the RN." The procedure the RN didn't document (Which meant it didn't even get billed for.) caused catastrophic results, which ended the patients life.
And, what happens when an RN DOESN'T document what she's done, the final records prove she did NOT document...and, the DON admits the RN didn't document it? The DON exact words: "It's just that it didn't get documented! We've discussed it with the RN." The procedure the RN didn't document (Which meant it didn't even get billed for.) caused catastrophic results, which ended the patients life.
What do you do about those instances?
Documentation for billing reasons v. documentation for "legal" reasons creates an interesting conundrum.
I would assume during a dep. the attorney would explore the statement "we've discussed it with the RN"
I also think that once the attorneys have a party admission, regarding the procedure being ordered, but not recorded, the focus would shift to "what caused the catastrophic results."
Further I really don't think the DON's admission would hold any weight unless she was physically there.
Coming from the legal field and going into the nursing field I find this all very interesting.
As an auditor, I review charts from facilites across the US. I am amazed at what is and isn't documented and I frequently have commented how in earth would some of the things I see stand up in court. Even with EMR, there will be pages of documents left blank or marked as "not assessed" so the clinician can get to the last entry field to chart on the patient with significant dementia "reminded patient to use call bell". It also important to realize that documentation is also used to support justification of billing, and definitely in that area, if it isn't documented, it didn't happen; and if it didn't happen it won't be reimbursed.
I see this everyday, people come into our office with all their "evidence" thinking it will hold up in court. What most people don't know is the rules of evidence, the thresholds to bring claims, each prong must be met and proven. So there are a lot of hurdles to be jumped. The fact that something isn't documented is not enough to prove negligence. It is probably enough to get you fired though. haha.
If anyone wants to read more about this, look into the rules of evidence, torts, civil procedure. etc
The procedure was never even ordered! The patient was my mom. Both my sister & I witnessed it. The RN laughed & said "We don't make very many friends when we do this", while our mom screamed out in horrific pain...went instantly semi-comatose & took her last breath 24 days later.
There are massive cover-ups throughout Mom's records.
What a nightmare it's been for us, but not near the horrific nightmare it was for Mom. We will never stop trying to get justice...not only for Mom, but all that have and will follow.
You don't ever stop hearing the horrid screaming she went through....it's there 24/7 365 days a year.
Yes, this is the Plan B that we use when the charting is not done: we argue that it is our usual and customary practice to do X, Y or Z; we can think of no reason why we would not have followed our usual and customary practice in this instance; and therefore just because it is not charted does not mean it was not done.
This is done to try and salvage a situation in which the charting is poor or non-existent. This line of argument does not carry near as much weight in the eyes of the jury as does an explicit chart entry, and it is easily subject to challenge on the basis of recall: 'Yes, this ED visit was two years ago, and I see 25 patients in the ED every day; and no, I cannot recall this particular ED visit, but I am sure that I did X, Y and Z based on my usual and customary practice'. Sometimes the jury buys this and sometimes they do not.
In my earlier comment, I meant to add that it's funny how in med mal cases, there's so much of the "if it wasn't charted, it wasn't done", but on the flip side, in our worker's compensation cases (where we represent the employers and insurance companies), we have so many employees who try to claim back, neck or shoulder pain so many months after a work accident. When there is no mention of this in the records, they claim that they told all of the physicians, nurses, etc. who assessed them, and the HCP's must have just forgotten to put it in the chart. It's amazing how many judges will allow that and render judgments in favor of the employees for these complaints.
Specializes in OR, Nursing Professional Development.
Surfandnurse said:
General question: how often does an RN actually lose his or her license over malpractice?
If you look over the disciplinary actions from the BON, you will find that the vast majority of them are for either drugs or alcohol impairing practice. You can probably find a list of these actions on the BON website or via a newsletter. Here's a link to PA's most recent list.
As difficult as this is to write about...sitting here feeling faint with a pounding heart...I do hope this will help at least one patient.
It was a totally unnecessary foley cath. (Mom had just used the bedpan.)
The nurse that did that to her has been for many years & still IS a CEN.
The DON tried to convince my sister & I there WAS no foley used, that's why it didn't get documented. QUOTE: "Why would there have been a foley, when the records state she'd used the bedpan?!" So, I pointed out the fact that in the records, the straight cath used to get the urine sample was done AFTER Mom had used the bedpan...and the words: "Tolerated well" were absolutely FALSE! That hurt Mom so badly, she cried out: "OW,OW,OW! What are you DOING?!" I explained to her they needed a urine sample. That hurt her so badly, she got VERY quiet & vomited. ( The urine sample came back with moderate blood. ) Then, came the horrid foley!
After Mom had used the bedpan, she even said: "Boy, what happened to me, this afternoon?!" I told her that maybe her bladder quit working for a little bit." (Mom had been making numerous trips to the bathroom and not doing anything...her abdomen was swelling and she got a splitting headache. She asked for my sister & I to call 911...we did!) In fact, the Chief Complaint on the ED records state: SEVERE HEADACHE
I had just had Mom to the doc for a physical 2 days earlier & all of her tests (including urine tests) all came back normal.
After they (DON & ED Supervisor, both female) "talked " with the CEN, they admitted there was a foley. I also got the hospital chain's headquarters to admit that, and I quote what was said to me: "Yes, it hurt & Yes, it made her bleed, but...she had dementia!"
As for the cover-ups throughout Mom's records? Each x-ray & scan showed NO foley cath...NONE! (I even had them all read, again by 2 different independent radiologists.) Yet, there were continuing records of the foley, in the 3 days Mom was in the hospital. I can still hear her screams coming from the x-ray room, to this day. I "know" now why she was screaming so badly. They were removing and replacing that foley...just like the CEN did in the ED.
Her white blood count soared while she was in the hospital for those 3 days...(TRIPLE of what they were 2 days earlier)... & not ONE antibiotic was given to her...not ONE! You couldn't lay a finger on her w/o her screaming out in pain. (THAT did get in her records.)
A few months later, the Governor of the state appointed that CEN to a state board!!! I wrote him 2 letters explaining what had happened & all I got back were the signed green return receipt's...proof that his office had gotten them.
We will NEVER give up trying to get justice for not only Mom, but...for every patient that has & will follow her.
Elderly women, & especially those that have had children, can make it very difficult, if not impossible to get a foley in them. Their internal body parts can fuse together. I've learned more about foley insertion than I ever thought possible & I know more than some CEN's, for SURE!
The hospice nurse told me Mom's foley was latex...Mom was allergic to latex!!!!!!!!!! Latex allergy is even on the EMS report. Mom wound up with Purple Bag Syndrome. The hospice nurse didn't know why the tube & bag were turning purple. I did a quick search on the web, found out what it was & told the hospice nurse. She'd never heard of it!!!
It's a nightmare & I've got to quit writing about it...I can't see through the tears, anymore. Talk about a bad case of PTSD.
This all happened on Mother's Day, 2013. Mom was a VERY healthy 86 year old.
I work in a med mal defense firm, and my boss pushes the exact opposite: just because it wasn't documented, doesn't mean it wasn't done. It comes up in depositions a lot, especially where we have assessments from our ER docs that were essentially left blank. A lot of them will later say that even though the form wasn't completed, they still did it, etc. and that sometimes they don't have time to complete the chart, especially in an emergent situation.
How ironic this was just covered in this weeks reading for my BSN. The example used was those of us working who are supposed to chart by exception. If I check cap refill at 8 AM and nothing changes until 3 PM it doesn't mean I didn't check in between...it just means it didn't change.
1Buckeye
4 Posts
That poor little baby!
And, what happens when an RN DOESN'T document what she's done, the final records prove she did NOT document...and, the DON admits the RN didn't document it? The DON exact words: "It's just that it didn't get documented! We've discussed it with the RN." The procedure the RN didn't document (Which meant it didn't even get billed for.) caused catastrophic results, which ended the patients life.
What do you do about those instances?