Application of Standards of Care

Look at the legal malpractice case study that has been assigned to your group. Describe the case and discuss the standard of care that the parties will be held to in this case. How will the standards of care and the Nurse Practice Act be applied in a court of law if the case is sued?

Case Study 2: Wrongful Death by Howard Carpenter on Behalf of Wilma Carpenter, Deceased

People Involved in Case:

Mrs. Wilma Carpenter — patient, deceased

Mr. Howard Carpenter — husband and plaintiff in wrongful death suit

Mrs. Scale, RN, MS — nursing supervisor

Elizabeth Adelman, RN — recovery room nurse

Richard Washington, MD — orthopedic surgeon

Judy Gouda, RN, NP

Joseph Alsoff, LPN — post-surgical unit nurse

Kelly Wheeler, RN — post-surgical unit nurse

David Casler, LRT

Susan Post, JD — risk manager

Amy Green — quality assurance

Michael Parks, RN, MS, CNS — education coordinator

Caring Memorial Hospital

Facts:

The plaintiff, Mrs. Carpenter, was a 55-year-old woman who underwent a total hip replacement at Caring Memorial Hospital. The physician was Richard Washington, MD. Dr. Washington is an orthopedic surgeon. His nurse practitioner is Judy Gouda, RN, NP. Dr. Washington reviewed the consent with Mrs. Carpenter prior to surgery. Joseph Alsoff, LPN, witnessed the consent and Mr. Carpenter was present. Joseph does not remember the doctor ever mentioning that death could be a result of the surgery. The recovery room nurse is Elizabeth Adelman, RN. The respiratory therapist is David Casler, LRT. The nurse on the post-surgical unit was Kelly Wheeler, RN. The supervising nurse was Mrs. Scale, RN, MS.

The patient had an epidural catheter for a post-operative pain management following an episode of hypotension in the recovery room which was treated with Ephedrine. Judy Gouda made rounds on the patient in the recovery room after the hypotensive event and vital signs were stable. The patient, Mrs. Carpenter, was placed on a medical surgical nursing unit with the epidural. The nurse, Kelly, was assigned to the patient and had not worked on that unit before, but had worked in post-acute critical care units. The nurse’s assignment was to provide patient care on the entire floor for that shift. There was also an LPN, Joseph, on the unit. It was a busy day on the unit. Mrs. Carpenter was not the only post-operative patient.

Kelly assessed the plaintiff upon admission, checked the IVs, asked if the patient was in pain, noted that the patient was responsive and understood where she was, and was stable. She then left to care for other patients.

The licensed practical nurse, Joseph Alcoff, had been working on the unit for several years. It had been rumored that Joseph was an alcoholic. There was no evidence that he had been drinking on the unit. Approximately an hour after the patient arrived on the unit, she was unable to tolerate respiratory therapy that was ordered and she became nauseated and vomited. David Casler administered the respiratory therapy. According to Kelly, the registered nurse, 10 minutes after the vomiting episode, Joseph Alcoff, the LPN, found the patient blue and unresponsive and called a code. Joseph is the only person other than the physician that carries his own liability insurance. The hospital also has malpractice insurance.

The code team responded, along with Kelly, the registered nurse. Mrs. Carpenter was intubated and cardiac resuscitation was initiated. The patient responded to resuscitative efforts and she was transferred to the intensive care unit. Subsequently, Mrs. Carpenter did not do well, was unresponsive, and declared brain dead and taken off the respirator. She did not have a DNR in place.

There is a conflict in testimony between Joseph the LPN and Kelly the RN. Joseph indicated that Kelly found the plaintiff to be unresponsive after the vomiting episode and called the code. The record is not clear as to when the vital signs and epidural site were assessed. Kelly said she did a motor and sensory level assessment and they were fine — it is not charted though. The time elapsed between the vomiting episode and finding the patient is in dispute. The final diagnosis was anoxia encephalopathy due to the time lapse between CPR being initiated. The patient was eventually extubated, breathed independently for a period of time, and then subsequently expired.

The vital signs ordered by the physician were hourly. The hypotensive episode in the recovery room had not been reported to the registered nurse.

The risk manager is Susan Post, JD, who works in collaboration with the quality assurance director Amy Green. Amy had noted when doing chart reviews over the last 3 months prior to this incident that the vital signs taken in the recovery room were not charted, not done, or not reported to the units. She was in the process of collecting data from the different units on this observation. She also noted a pattern of using float nurses to several postoperative units. Prior to this incident, the clinical nurse specialist, Michael Parks, RN, MS, CNS, was consulting with Susan Post and Amy Green about the status of staff education on these units and what types of resources and training was needed.