Donna did not have to die.
The cell phone rang (or rather vibrated) at the worst possible time-in the middle of a Vickie Milazzo lecture. We were in Orlando for the CLNC [R] 6-Day Certification Seminar. We both had successful full-time careers and had performed some legal nurse consulting over the years. Our goal in becoming CLNC [R] consultants was to continue our lifelong learning, rather than to change career paths.
The Magic Kingdom was distracting enough. And now in the middle of Vickie's lecture, that darn cell phone was vibrating.
At the next break, we returned the call to an RN we had met a few weeks earlier while consulting for her agency. We had mentioned our excitement at becoming Certified Legal Nurse Consultants [CM] and she had told us about her grandmother's death at a local nursing home.
The RN was calling us to provide legal nurse consulting services for her family's attorney. The nursing home attorney had presented a settlement offer, but her family was not pleased with the offer. As Vickie teaches, we told her that we could only work directly with her family's attorney.
A few days after the seminar, the family's attorney called and hired us as consulting experts. After discussing the case, and with Vickie's teachings fresh in our heads, we asked the attorney for:
* The patient's nursing home records and hospital records.
* Nursing home staff competencies, evidence of licensure, performance appraisals, ongoing education and training records.
* Copies of state or federal licensing survey reports on the nursing home during the applicable period.
* A copy of the complaint.
* Any other documents relevant to the case.
We Planned Our Work
When the records arrived, we found ourselves frequently referencing the Core Curriculum for Legal Nurse Consulting [R] textbook. The module on "Comprehensive Case Evaluation Strategies" directed the design of our work plan, which included these steps:
* Communicate with the attorney-client initially and throughout the case.
* Scan the case.
* Develop and implement a plan of action.
* Organize the medical records in chronological order.
* Assess the records and relevant documents.
* Use relevant records and documents to establish the facts and analyze the case.
* Identify and access supporting literature.
* Develop demonstrative evidence.
* Identify applicable standards of care and deviations from those standards.
* Assess the plaintiff's damages.
* Prepare and submit our report to the attorney-client.
With our new-found knowledge from Vickie Milazzo Institute, our CLNC [R] credentials, the Core Curriculum, our work plan and free access to CLNC [R] Mentors, we were ready to go to work.
Donna, the patient, had resided in a nursing home for several years. She had been alert and independent in her ADLs (activities of daily living) until she suffered a fall. Within two weeks, her health declined rapidly. Finally, at the insistence of her family, she was transported by ambulance to a local medical center. Donna was admitted to the medical center with sepsis, renal failure and an intra-abdominal viscous rupture. Her health continued to rapidly decline, and she died six days later.
We Worked Our Plan
Here we were, brand new CLNC [R] consultants with our first case post-class. What had we just learned from Vickie? How could we help?
As soon as we reviewed the complaint, medical records and other documentation, we knew the case needed demonstrative evidence. We had never done this, but our favorite module in the CLNC [R] 6-Day Seminar was "Helping Attorneys Develop Demonstrative Evidence."
We first developed a timeline of the patient's decline in the nursing home, starting with her fall. We identified dates, times and actions taken by the staff for these key indicators of decline:
* Complaining of pain immediately following the fall.
* Ongoing complaints of pain in the left hip and shoulder, chest pain, bilateral rib cage pain and lower abdominal pain.
* Elevated temperature 24 hours post-fall and spiking temperature thereafter.
* Increased confusion.
* Her abdomen becoming rigid and distended, and her screaming when her abdomen was touched.
* Diminished urine output.
* Spitting out and refusing medications.
* Oxygen saturation decreasing to 90 percent.
* Refusing all oral intake and intermittent vomiting.
* Becoming unresponsive.
Based on the hospital record, we then developed a timeline of the patient's care in the medical center. This timeline included:
* Arrival in the emergency room with sepsis, dehydration and acute renal failure.
* The hospital course:
* Diagnosed with an intra-abdominal viscous rupture. * Deemed not a surgical candidate due to the extreme risk of surgery. * Family requested a do not resuscitate order. * Decline continued with high temperature, abdominal distention, few bowel sounds and response only to painful stimuli.
* Death on the sixth day.
Our final timeline detailed the lost opportunities to save Donna's life. This timeline showed dates, times, passive treatment by the nursing home staff and deviations from the standards of care.
The standards of care module from the CLNC [R] Certification Seminar guided us in developing this portion of our work plan. We researched the state nursing practice act and state and federal nursing home laws. Using these standards, we defined numerous deviations in care:
* Failure to implement an appropriate fall prevention program.
* Failure to formulate a nursing care plan for new problems (pain and nutrition) with defined interventions and goals.
* Failure to observe a medication's action (pain medication was ineffective).
* Failure to identify uncontrolled pain as a problem.
* Failure to derive a nursing diagnosis or identify issues based on assessment data.
* Failure to monitor or observe a change in the patient's clinical status.
* Failure to communicate to the physician a significant change in the patient's condition.
* Failure to collect comprehensive data pertinent to the patient's health or clinical situation.
* Failure to make prompt, accurate entries in the patient's medical record.
Vickie's "How to Research Medical-Related Cases" module taught us the importance of creating a search strategy and obtaining additional relevant information. We accessed the state Department of Health and Environmental Control (DHEC) website looking for standards of nursing home care. Not only did we find the standards, we discovered that the nursing home had a DHEC survey on the very day Donna's family had her transferred to the hospital. The survey results were posted on the DHEC website as public information.
We developed another graph showing the results of the state survey inspection most relevant to the case. The following deficiencies were cited:
* Failure to give each resident care and services to attain or keep the highest quality of life possible.
* Failure to properly care for residents needing special services.
We also accessed the Centers for Medicare & Medicaid Services (CMS) website and found national, state and nursing home specific comparative data regarding appropriate staffing levels. We developed a graph demonstrating that the defendant nursing home was well below both state and national averages for:
* Licensed RN hours per resident per day.
* Licensed LPN/LVN hours per resident per day.
* Total licensed nursing staff hours per resident per day.
As Vickie taught us, we concluded our report by citing literature and Internet references. We then submitted the report to our attorney-client for review. Following a telephone conference with our attorney client, he discussed our findings with the defense attorney.
Our Findings Resulted in a 57% Larger Settlement
During the next settlement hearing, the defense attorney offered a 57 percent increase in settlement on behalf of the nursing home. The family accepted this new offer. Donna's granddaughter shared her family's sincere appreciation, not just for the increased settlement, but for bringing to light the nursing home's deficiencies from the state survey.
This case taught us the practical application of all the strategies and tools from Vickie Milazzo Institute's CLNC [R] Certification Program. This case was memorable because:
* We received the first telephone call about this case before we even left the CLNC [R] Certification Seminar.
* We were immediately able to implement many of the strategies we had just learned.
* We were able to start recovering our costs of the CLNC [R] Certification Program immediately.
* We keep Donna's picture, smiling and happy, surrounded by her loving family, balloons, flowers and a cake, celebrating her birthday-just a short time before her fall.
Kathy J. Morgan, RNC, CLNC is president and consultant with HES, Inc. She had 13 years experience with the Joint Commission as a nurse surveyor and specializes in federal regulatory and accreditation-related cases. Sharon L. Johnson, RN, CLNC works in acute care hospital administration and is a CLNC [R] consultant with HES, Inc., specializing in federal regulatory and acute care cases.
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