Situations Where Documentation Went Wrong

Let's take a look now at some real legal cases where nursing documentation either was, or soon became, a critical issue in the case.

Ketchum vs. Overlake Hospital Center

Ketchum vs. Overlake Hospital Center

We will begin with Ketchum vs. Overlake Hospital Medical Center, 1991, in which Ms. Ketchum's family filed suit against Overlake Hospital, contending that Ms. Ketchum suffered severe brain damage caused by what they felt was negligent nursing care. Their complaint focused on the care she received in Overlake's Intensive Care Unit on the night shift back in 1980 following an operation in which an aneurysm in her brain was surgically clipped.

The bottom line in the case was whether or not the night nurse caring for Ms. Ketchum had accurately and completely assessed, documented and reported changes in her condition during the night. A nurse expert witness for the prosecution testified that the nurse had not adequately documented symptoms of client deterioration such as respiratory distress, an elevated pulse and sluggish pupils. The expert nurse also testified that the night nurse had not notified the physician of the changes in his client's condition either.

The defense nurse expert witness testified that the nurse had satisfied the standard of care for a patient with Ms. Ketchum's condition in regards to both assessment and documentation. Moreover, this expert testified that the nurse had fully and appropriately informed the client's doctor about her condition in three phone calls she had made to him that night.

Although this case had to return for a new trial due to a technicality, it appears from the nurse experts' differences of opinion that this particular nurse's documentation of the assessment of Ms. Ketchum on that particular night may still be a pivotal issue in this lawsuit.

Jarvis vs. St. Charles Medical Center

Jarvis vs. St. Charles Medical Center

Another interesting case is Jarvis vs. St. Charles Medical Center, 1986, in which Ms. Jarvis suffered a leg fracture in a skiing accident in 1981, which was subsequently surgically reduced. Concerned about a condition called compartment syndrome (swelling prevents blood from reaching a muscle compartment), the doctor left orders for nurses to perform certain tests and observations on an hourly basis and to call him if problems developed.

Nurses did call the doctor on one evening to report problems, which he immediately alleviated. However, on one particular morning the client's leg was white and had no pulse when the doctor examined her on his morning rounds. He had not been called during the night with any report of problems, but some of the leg tissue was indeed dead and the client had to have more surgery to remove that tissue. The result was that the client had decreased use of the involved leg.

During litigation, the court was asked to determine if inconsistent nurses notes regarding the testing and assessment ordered by the client's doctor were indicative of substandard care that led to the client's further injury and suffering. The court concluded that the faulty charting did indicate less than optimal care, which resulted in the client's current unfortunate condition. In fact, this case truly epitomizes the old saying that if the care was not documented, then it was not done. In this case, the record truly could not come to the nursing staff's defense because during a four and one-half hour period no documentation of any assessment of the client could be found in the record. It was as though a nurse never checked the client during that time period.

Ard vs. East Jefferson General Hospital

Ard vs. East Jefferson General Hospital

A third case highlighted in the January 1997 issue of the NSO Newsletter (p.5) is Ard vs. East Jefferson General Hospital [Source: Ard v. East Jefferson General Hospital, 636 So.2d 1042 (LA, 1994)] where five days after quintuple coronary artery bypass graft surgery, a patient who was having respiratory problems was transferred out of the intensive care unit (ICU). But two days later, this patient, who had a history of myocardial infarction, stroke, and unstable angina, was readmitted in respiratory failure. Five days after that, he was again transferred from the ICU.

According to his wife, he became nauseated and short of breath after leaving the ICU for the second time. She recalled pressing the call light several times before someone responded.

His nausea worsened; then he vomited and began tossing and turning with pain. A nurse gave him a suppository at about 5:30 pm.

From 5:30 to 6:45 pm, the patient's wife claimed she pressed the call light 10 or 12 times, each time asking for a nurse. She was told that a nurse wasn't available. Her husband was having difficulty breathing. At 6:45 pm, he went into respiratory arrest. The patient's wife ran into the hall and found a nurse, who initiated a code.

Despite resuscitation efforts, the patient died of respiratory and cardiac arrest two days later; he'd never regained consciousness. His wife sued the hospital for wrongful death.

At the trial, the nurse assigned to care for the patient disputed the wife's testimony. She said she'd checked the patient at about 6 pm. However, her assertion wasn't documented in the patient's record. In fact, there was no indication that any nurse checked on the patient between 5:30 and 6:45 pm.

A nurse testifying as a nurse expert witness cited this as an example of a serious breach in the standard of care. Also, she said, the nurse's notes and the plan of care failed to address the patient's swallowing problems and high risk of aspiration. No swallowing assessment was ever done and the nurse didn't do a full assessment of respiratory and lung status after the patient vomited.

A medical expert also testified that timely notification of the patient's worsened condition might have changed the outcome. The patient could have been transferred to the ICU, where his chance of survival would have been better.

The trial judge ruled in the plaintiff's favor. The hospital appealed, but the appellate court affirmed a lower court's ruling. It also increased the amount of damages awarded to the wife from $50,000 to $150,000 and to the patient's adult daughter from $10,000 to $50,000.

What is the lesson to be learned from this case? A high-risk patient requires complete assessment and frequent monitoring. And unless these measurements are documented, the court may not recognize that they've been performed. In this case the court didn't believe the testimony of the nurse who claimed she'd checked the patient. The wife's testimony, however, was consistent with the medical record.