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Nurses fail to disclose decubitus ulcers: punitive damages awarded. (Nursing Law Case of the Month).

CASE ON POINT: NME Properties, Inc. v. Rudich, 2003 WL 289415 So.2d -FL

ISSUE: Despite all of the advances in medical technology one of the oldest and most recurring complaints of patients relates to decubitus ulcers. In this unusual case, nurses failed to chart a patient's decubitus ulcers. Consequently, the patient's attending physician was not made aware of the condition in a timely manner. Ultimately, the patient had to be removed from the nursing home where the ulcers developed when they reached a condition that required hospitalization.

CASE FACTS: Ida Revitz was admitted to Menorah House, (Menorah) a nursing home, in July of 1992. The patient was in the middle phase of Parkinson's Disease, incontinent of bowel and bladder, had moderate to severe dementia, memory problems, and limited mobility. She was totally dependent on Menorah personnel for mobility. Menorah had written policies and procedures concerning the care and monitoring of decubitus ulcers including record keeping requirements regarding the treatment and status of ulcers as well as for notifying physicians and the Director of Nursing. The treatment nurse was responsible for filling out pressure ulcer reports and documenting residents' decubitus ulcers. Those reports were not contained in the residents' charts. Menorah's Director of Nursing maintained that it was the nursing home's responsibility and that of its staff to provide residents with the appropriate observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care. After the patient suffered an 11-pound weight loss and a brief admission to a hospital where tests suggested colon cancer, she was readmitted to Menorah on October 17, 1994. At that time, the patient did not have any decubitus ulcers. Records indicated that from December 16 to December 26, 1994, the patient was not bathed or showered. That was supposed to be done on a daily basis. On December 24, Desitin was applied to the patient's right hip and buttocks on a daily basis until the area was healed. On December 29, the patient acquired a Stage Two decubitus ulcer on her coccyx, approximately two centimeters in size. A Ferris Polymer gel-filled pad was applied to the patient's right hip. No physician's order was entered for treatment. A Stage Two ulcer required that a physician be notified. No physician was notified until January 9, 1995. No treatment was rendered. the ulcer at the time it was discovered. The patient's chart contained no updates on the status of her ulcers. A January 2, 1995, pressure ulcer report stated that the ulcer on the patient's coccyx was acquired on December 29, 1994. However, the nurses' notes made no mention of it until January 9, 1995. The treatment nurse did not obtain a separate order for treatment of the coccyx ulcer but claimed that she "must have used the order written for the right hip." On January 9, nurse's notes described the ulcer as a Stage Four ulcer, 4 1/2 x 5 centimeters in size. A pressure ulcer report of that same date reflected a 3 centimeter, Stage Three ulcer. Dr. Aaron was contacted. He prescribed a cleansing treatment. This was the first record of any treatment of the ulcer on the hip. The ulcer on the patient's left hip was first noted on January 16. By that time, the patient's ulcers had not improved. Saline was prescribed as a cleaner. By January 24, the coccyx decubitus ulcer was 8x4 centimeters, and the left hip ulcer was 4 centimeters. The patient's daughter was not notified of her mother's ulcers until January 24, when she was discharged from the nursing home and taken to the hospital. Once at the hospital, Dr. Aaron recommended a plastic surgeon regarding the ulcers or a Hospice consult. The patient was discharged to Hospice where she died on February 4, 1995. The patient's daughter Florence Rudich brought suit against NME Properties, Inc., owner of Menorah, seeking both damages for medical expenses, pain and suffering and punitive damages. After a trial, a jury returned a verdict for nearly One Million Dollars, including punitive damages of $800,000. Menorah appealed.

COURT'S OPINION: The District Court of Appeal of Florida affirmed the judgment of the lower court.

LEGAL COMMENTARY: The court rejected Menorah's contention that because it hired a management company, which both employed and paid its nurses, Menorah was not liable for, inter alia, punitive damages. The court held that this did not insulate the defendant from punitive damages. The court likened the "rule of non-delegable duties of licensees "to the rule of Respondeat Superior in tort law. Menorah was not insulated from liability by the management agreement.

Meet the Editor & Publisher: A. David Tammelleo, JD, is a nationally recognized authority on health care law. Practicing law for over 40 years, he concentrates in health care law with the Providence, R.I., firm of A. David Tammelleo & Associates. He has presented seminars on medical, nursing and hospital law throughout the United States. In addition to his writings as Editor of Medical Law's, Nursing Law's & Hospital Law's Reagan Reports, his legal articles have been published in the most prestigious health law journals. A prolific writer, his thousands of articles, as well as his achievements as an attorney and lecturer, have won him recognition in Martindale-Hubbell's Bar Register of Preeminent Lawyers, Marquis Who's Who in American Law, and Who's Who in America.
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Author:Tammelleo, A. David
Publication:Nursing Law's Regan Report
Geographic Code:1USA
Date:Feb 1, 2003
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