I'm sure you are familiar with the importance of adhering to your nursing standard of care for patients. As I have noted in previous a previous blog, your standard of care in a professional nursing malpractice case is based on applicable standards of practice such as the nurse practice act and position statements from your professional nursing organizations. In a 2021 Louisiana appellate court case, the court articulated the requirement of proving that a standard of care was indeed breached.
Elements of the Case
In this case, the female patient was admitted to the medical center for treatment of a staph infection connected to her existing medical condition, scleroderma. When treated with antibiotics for the infection, acute renal failure resulted, and the patient required dialysis. While on dialysis, the patient experienced seizures which required resuscitation. She was admitted to the ICU for further treatment, which included placing her on a ventilator, and her plan of care included "seizure precautions." On the patient's first day off of the ventilator, she "[was] alert, talking, ate breakfast, and participated in a physical therapy session." When she completed the therapy session, she asked an ICU nurse to close her privacy curtain so she could rest.
When a phlebotomist entered the patient's room about 20 minutes after the curtain was closed, the patient was found unresponsive on the floor. A code blue was called, and the patient was re-intubated and placed back on the ventilator. Approximately 10 days later, the patient's ventilator was removed, as she had no brain activity.
The cause of death was determined to be "anoxic brain injury...secondary to cardiac arrest, secondary to renal failure, and secondary to scleroderma." Eight months after her death, the patient's siblings filed a malpractice case against the medical center alleging numerous failures on the part of the medical center's staff in properly monitoring the patient, both physically and by telemetry, and responding to the late patient's medical needs.
Medical Review Panel's Finding
Consistent with state law, a medical review panel reviewed the complaint. The medical panel, composed of three expert physicians, "unanimously concluded" that there was no deviation from the standard of care by the medical center. As to the nursing staff's conduct, the panel found that the ICU nurses followed protocol regarding side rails and fall precautions. It further found that it was appropriate to honor the patient's wishes to close the privacy curtain. The panel's additional findings indicated that the patient suffered many afflictions, including scleroderma, pulmonary hypertension, and methicillin resistant staph cellulitis.
The medical center filed a Summary Judgment Motion, stating that there was no medical expert testimony to support the siblings' case. The siblings opposed the Summary Judgment Motion but did not identify a medical expert. Rather, their position was that the negligence against the medical center should be inferred.
They also raised the doctrine of res ipsa loquitur ("the thing speaks for itself"), arguing that the circumstances suggest that the fall would not have occurred but for the medical center's negligence, that the medical center had control over her care, and that there was no other plausible explanation for her fall and death. The trial court granted the medical center's Summary Judgment Motion and dismissed the case with prejudice (meaning that it could not be refiled).
Appellate Court Decision
The late patient's family's appeal was based on her suffering and death. They alleged that the closure of the privacy curtain, along with inappropriate telemetry monitoring, was a deviation from the standard of care in an ICU room. The court supported its decision by citing state law and cases. It began by pointing out that the medical center clearly met its initial burden of proving it was entitled to Summary Judgment as a matter of law due to the medical review panel's decision. Because the medical center met its burden of proof, the burden shifted to the siblings to produce facts to support their contention that there was a breach of the standard of care and that breach caused their sister's death. The siblings did not present any facts to allow the court to deny the Motion for Summary Judgment. Moreover, they did not present as evidence an expert medical opinion. The court also held that the doctrine of res ipsa loquitur was not applicable in this case, as it can only be applied when there is factual evidence and "sufficient circumstantial evidence to suggest the only reasonable cause of injury, in the context of a medical malpractice action, is a breach of the standard of care."
The evidence in the record, the court opined, failed to eliminate other more probable causes of the patient's death than negligence, including her previous seizure history, the possibility that her telemetry monitor was disconnected as she attempted to get out of bed without assistance, and that her death was from a lack of oxygen.
The court affirmed the lower court's granting of the Summary Judgment Motion and dismissed the case against the medical center.
How This Standard of Care Case Affects You
There is no question that you have a legal and ethical obligation to protect your patients' privacy, which includes an individual's right to get away from the "hustle and bustle" of a busy hospital environment. This is especially so when a patient requests the closure of a privacy curtain or a room door. But, as this case makes clear, there remains a continuing obligation for nursing staff to assess the patient and provide care consistent with the standard of care in the situation. The nursing staff's documentation regarding the care of the patient on the day of her death, both before and after the privacy curtain was closed, was an essential, factual basis for the court's decision. Be sure to accurately document all aspects of the care you provide to patients, including flowsheets, nursing notes, and communications. Finally, ensure that you are up to date with all aspects of the monitors you work with and that your skillset regarding them is current.
Take these related courses:
HIPAA and Confidentiality: Practice May Change, But Principles Endure
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The federal Health Insurance Portability and Accountability Act (HIPAA) was implemented in 1996 and has been revised since then. HIPAA can refer to guidelines that protect your ability to maintain your health insurance as you move from job to job or place to place ("portability"). HIPAA can also refer to efforts to simplify the administration of health insurance. These efforts include the creation of national standards for diagnostic terms, insurance forms, and provider identification. Perhaps the most common use of the term for healthcare professionals, however, involves protecting the confidentiality and privacy of healthcare information. In this course, you will learn about parts of HIPAA, especially as they concern nursing and other health professionals and the protection of healthcare information. Because you play a key role in the production of healthcare information, you play a key role in its protection.
Ethics for Nurses
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Healthcare professionals are held to high standards of moral character and an expectation to be patient advocates. This innate drive to do "what is right," arguably a prerequisite for pursuing a career in patient care, is rooted in history, law, clinical education, and current daily practice. What do we do when this line is blurred, and no clear answer appears to all involved parties? This course seeks to give the nurse understanding of past, present, and future practices of ethical decision-making in the acute care setting as well as how to manage instances when our own values and judgement do not align with that of the patient, family, or care team.
Protect Yourself: Know Your Nurse Practice Act
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