SAMPLE CASE 1
John Lawyer
Attorney at Law
100 ABC Street
Anycity, Anystate 20000
RE: Jane Doe vs. Home Medical Center
Dear Mr. Lawyer,
Upon reviewing the records on the above case, there is evidence of deviations from the standards of nursing practice which led to the injury and subsequent death of Jane Doe.
On the admitting assessment, nursing failed to recognize comprehensively her risks for injury. Risk factors that were evident by the medical record include:
1. Contributing medical diagnosis
A) History of subdural hematoma secondary to fall
B) Stroke
C) Seizure disorder (Generalized seizure with loss of consciousness occurring every 6 to 12
months)
D) Hepatic encephalopathy
E) Acute Inflammatory Demyelinating Polyradiculopathy (AIDP)
2. Age, greater than or equal to 75 years
3. Current medications
A) Lasix
B) Lactulose
4. Mental Status
A) Impaired short term memory
B) Poor practical judgement
5. Mobility
A) Required a walker with assistance
B) Patient's complaints of weakness
6. Sensory - impaired vision
7. Elimination - history of urinary incontinence
Nursing appropriately made a care plan for potential for injury and potential for seizures. Included in the care plan, but not limited to are the following interventions:
1. Assess potential for injury every shift, to include mental status, gait, balance and muscle strength.
2. Bed with side rails up.
There is inadequate shift to shift assessment of this patient's risk of injury. What documentation that is present indicates that the patient was anxious from 07/10/93 through 07/16/93 and angry (07/13/93 to 07/14/93), without further explanation or follow up.
She was having frequent diarrhea without follow up with a physician. There is no evidence of assessing the patient's need for a bedside commode, adult incontinence briefs or physical restraint. On 07/11/93, it is noted by nursing staff that "restraints not needed at this time. Responds inappropriately at times. Needs definite directions and instructions with Activities of Daily Living (ADLs)".
The patient's bed had 4 side rails. On 07/08/93, 07/13/93 and 07/14/93, only 2 side rails were up. On 07/12/93 and 07/15/93, 3 side rails were up. On the evening of 07/15/93 the following is noted in the chart, "patient put on light every five minutes", "assist to the bathroom every five minutes", and "all 4 side rails were up". On 07/16/93 at 5:35am, it is noted in the chart, "patient found on floor", the "bed was in low position with all 4 side rails up". It was also noted that "patient was reminded frequently by all staff to remain in bed and use call light, wait for assistance to go to the bathroom."
It is my conclusion that the nursing staff did not meet nursing standards of care in the following areas:
1. Inadequate assessment of patient risk for injury at the time of admission and ongoing shift to shift
assessment.
2. Care plans were not followed.
3. Failure to report to physician frequency of diarrhea and frequency of trips to the bathroom.
4. Failure to assess the need and provide for alternatives, such as: bedside commode, incontinence
briefs, physical restraint or companion or sitter for the patient who required frequent reminders to
remain in bed, use call light and wait for assistance to go to the bathroom.
The above deficiencies led to the injury and subsequent death of this patient.
Thank you for allowing me to review this case. If I can be of further assistance to you, please feel free to call me.
Sincerely,
Amor C. Agdeppa
RN, BSN, CLNC