Case Study #1: Failure to adequately assess and monitor the patient post operatively resulting in the patient's death

NOTE: There were multiple co-defendants in this claim who are discussed in this scenario. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited to the actions of the defendant; the nurse.
The decedent/plaintiff was a 67 year old male who underwent a right total knee replacement. Following the procedure, the plaintiff was treated in the post-anesthesia care unit where an epidural catheter was inserted for postoperative pain management.

Following one episode of hypotension which was treated successfully with ephedrine, the plaintiff was discharged to an inpatient medical-surgical care nursing unit with the epidural in place. Although the defendant nurse customarily worked on the post-acute critical care unit, she had been re-assigned to the medical-surgical nursing care unit. The defendant nurse stated that she understood her assignment at the time of the plaintiff's admission to this unit was to provide oversight of the patient care on the entire floor for that shift.

The defendant nurse assessed the plaintiff upon his admission to the unit and found him to be stable. The defendant nurse understood that the direct care of the plaintiff was assigned to a c-defendant licensed practical nurse (LPN). Approximately three hours after arriving on the unit, the plaintiff was unable to tolerate ordered respiratory therapy due to nausea and vomited shortly thereafter.

According to the defendant nurse, approximately ten minutes after the episode of vomiting, the LPN found the plaintiff cyanotic and unresponsive and immediately called a code.

The defendant nurse responded, as did the code team, and the plaintiff was intubated and transferred to ICU. This account of events was disputed by the LPN and two other staff on the unit who understood that the defendant nurse was responsible for the direct care of the plaintiff.

The LPN stated that it was the defendant nurse who found the plaintiff to be unresponsive at some point after the episode of vomiting and called the code herself. The elapsed time between the episode of vomiting and the code is also disputed. The eventual diagnosis was anoxic encephalopathy due to the time that elapsed before CPR was initiated. The prognosis was poor and life support was withdrawn. The plaintiff breathed independently and was transferred to hospice care where he subsequently expired.

Ordered vital signs and checks of the xyphoid process were not documented. The fact that the plaintiff had experienced hypotension in the recovery room should have warranted even closer observation. The episode of nausea and vomiting should have resulted in additional observation and notice to the physician.

Resolution

Experts determined that the defendant nurse had breached the standard of care.

Discussion

1. Summarize the case and the verdict.

2. Based on your review and summation, do you agree with the court's decision? Defend/discuss your answer.

3. What practice-related legal and/or ethical issues as they pertain to Health Care management were breached? How? By whom?

Include the nurse as well as ALL other possible defendants. DEFEND your answer.

4. Identify and document a risk management action plan to prevent this type of issue(s) from reoccurring.