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News: A Veterans Affairs hospital settled for $500,000 with an elderly diabetic patient who suffered gruesome complications due to allegedly poor nursing care.
Background: The patient was a 75-year-old retired chef who had been admitted on Oct. 15, 1993, diagnosed with a mild stroke. The case centered around the care and treatment he received in the hospital until Nov. 22, 1994. The patient claimed his care began to deteriorate upon his transfer to the rehabilitative ward. He developed bedsores, which were complicated by diabetes and peripheral vein disease. He continued to receive poor nursing care, he claimed. Gaps in nursing notes appeared, occasionally for entire shifts, according to court documents.
In May 1994, the patient scratched himself near his groin, causing an open wound. The patient claimed poor nursing care caused infection and gangrene in the groin, necessitating surgical castration, a permanent colostomy, and cystotomy. He underwent 23 surgical debridements under general anesthesia. The patient also claimed that poor management of his foot ulcers ultimately led to an above-the-knee amputation of his right leg. He has been bedridden since that time. The hospital was prepared to argue that due to his medical history, the patient likely would have developed these problems and that the surgery was necessary to save his life.
What it means to you: Margaret Radzwill, RN, BSN, offers an overview of the potential risk management and quality of care issues that arise in this case:
"It seems that this 75-year-old gentleman experienced multiple complications stemming from other chronic medical conditions, primarily diabetes and history of peripheral vascular disease [PVD]. As such, this case raises several issues concerning the appropriate management of his diabetes during his inpatient stay on the medical and rehab unit, as well as initial and ongoing nursing assessment and care management by all interdisciplinary team members who were likely involved with his care.
o Appropriateness of initial and ongoing assessments.
"Since the patient's primary diagnosis was a mild stroke, it is assumed that he was admitted to the rehab unit for neuromuscular rehabilitation. In this regard, it is not evident that this patient initially had a comprehensive assessment that focused on a complete systems review, with special focus on cardiovascular assessment and nursing safeguards taken for maintaining skin integrity and preserving circulatory status, given the patient's PVD history and later development of decubiti and foot ulcers.
o Failure to report and act on patient's declining circulatory status.
"Another consideration was whether the nurse and/or physical therapy staff reported the patient's declining circulatory status to the physician, and whether the patient received further evaluation of his PVD for medical or surgical treatment considerations.
o Aggressive diabetes management during hospitalization.
"It is not known whether the patient's blood sugars were appropriately monitored by nursing staff and treated accordingly by the proper consulting physician. Due to the patient's diabetic-related outcomes, it seems that his diabetes was poorly managed for some time.
However, poor glycemic control during his hospital stay may have contributed to his declining peripheral vascular status and his susceptibility to infection, which resulted in a bowel gangrene and subsequent surgeries.
Daily glucometer testing and periodic hemo globin A1c monitoring would have assisted staff in measuring the effectiveness of the patient's glycemic control, as well as served as a liability defense measure — provided the evidence showed that actions were taken to improve his glycemic control.
o Processes for identifying patients who are no longer rehab candidates due to worsening medical conditions.
"Another consideration is whether this patient was an appropriate rehab candidate once he began to develop loss of circulatory integrity. It seems that the patient may have benefited from transfer back to the medical floor for more aggressive evaluation and treatment intervention.
o Nursing/staff documentation omissions — a risk management nightmare.
"Certainly the gaps of nursing documentation necessary to support the level and extent of care provided to this patient raise serious concerns about the appropriateness of the nursing and rehab care he received. Those documentation omissions made this case difficult for the health care facility to defend from a professional liability perspective.
o High-risk patient identification requires more nursing interventions during the care planning process.
"All patients with complex co-morbid conditions, as described for the patient in this case, should be treated as high risk, and nursing interventions should be planned accordingly to prevent treatment complications. Vigilant attention to glycemic control and maintenance of skin integrity for such patients is essential for quality medical care and should be included in a multi-disciplinary team effort to prevent complications. Nurses, aides, physical therapists, and the treating physicians all share in this role."
Porter v. U.S.A. (Bronx V.A. Hospital), U.S. District Court, Southern District of New York, Case No. 96 Civ 6266.
Margaret Radzwill, RN, BSN, is a consultant with Healthcare Management Consulting Services, in Houston. She specializes in clinical risk management, integrated utilization/quality management, and development of disease/case management programs for hospitals, medical groups, and managed care organizations.