court cases re: documentation. case # 1 pt, post-cva, post cabg, with peg tube 70 y/o male suffered...
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COURT C
ASES RE:
DOCUMENTATI
ON
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CASE # 1
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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PT, POST-CVA, POST CABG, WITH PEG TUBE
Pt’s family filed a negligence claim against the hospital and members of the nursing staff.
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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.
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PT, POST-CVA, POST CABG, WITH PEG TUBE
The hospital and the pt’s family agreed to a confidential settlement.
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LESSONS LEARNED
When a nurse is accused of negligence, ignorance of the standards of nursing care does not serve as a viable legal defense.
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LESSONS LEARNED
“The RN attains knowledge and competency that reflects current nursing practice.”
ANA Standards of Professional Performance
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LESSONS LEARNED
If there’s no documentation, there is no evidence.
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LESSONS LEARNED
Jurors cannot assume that a patient received care if a nurse failed to document it.
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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.
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LESSONS LEARNED
The documentation must also include the physician’s response and any new orders.
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LESSONS LEARNED
The nursing response to an adverse event must also be documented in the pt’s record.
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CASE # 2