Nursing Standard of Care: Just following orders? Part 1

I have had the questioned posed to me by an attorney in a deposition (on more than one occasion), “So you think you know more than the doctor”? The nurses’ responsibility does not end with blindly following a physician’s order. I have personally testified at 3 depositions and was asked this question at 2 of them.

Nursing Standard of Care

How does the nurse bear responsibility when things go wrong with a patient due to the nursing standard of care not being met?

What is the Nursing Standard of Care?

Let me tell you the story of Keith McWilliams (name changed), a 49-year-old man who presented to the ED with severe, sudden onset, 10/10 pain to his neck. He had a history of an aortic valve replacement and was on Coumadin at home.

In this case (which settled before trial), I was contacted by an attorney to review a case as an expert witness and give him my opinion. Did the ER nurse follow the standard of care in administering Dilaudid in the Emergency Department?

Here are some of the important facts that were not known by the healthcare personnel in the Emergency Department

• Keith hit his head on a piece of wood three days prior.
• He was a chronic, heavy user of alcohol.

Keith’s Course of Treatment While in the Emergency Department

Initial Vital Signs
• Blood pressure: 186/72
• Heart Rate: 84

Medications given

• Dilaudid 1 mg IV x 1
• Toradol 60 mg IV x 1

Discharge Vital Signs

• Blood pressure: 204/64
• Heart Rate: 56

Level of Consciousness: Very somnolent; difficult to arouse; unable to sign discharge instructions; sent home with a friend providing transportation.

Total time in Emergency Department: 75 minutes.

Did the ER staff meet the nursing standard of care for pertinent documentation?

• The RN notified the resident that the patient was difficult to arouse prior to discharge.
• The RN documented with last set (2nd set) of vital signs that the patient’s pain level was “0”.
• The discharge order was written prior to the last set of vital signs being documented.

Documentation That Was Not Present

• There was no documentation written while the patient was in the Emergency Department that indicated that the patient was questioned regarding any injuries that may have caused the neck pain.
• The following day, after she was notified that the patient had been brought back to the Emergency Department with a huge head bleed, the attending physician wrote a note stating that Keith denied any head injury and dated this progress note with the day of the patient’s being seen in the Emergency Department.
• There was no documentation to suggest any diagnostic testing was done.
• There was no documentation, at any time, that a comprehensive neurological exam was performed.
• Again, there was no documentation that the RN pointed out the initial or discharge vital signs to the physician.

The resident and attending, in their depositions, stated that they were not aware of the patient’s discharge vital signs (and would not have discharged the patient if they had been made aware of his blood pressure).

What Occurred After Discharge from the Emergency Department?

• Keith’s friend dropped him off at his home.
• Keith’s wife stated the next day that he went directly to bed after arriving home and was uncommunicative.
• His wife found him the next morning in bed unresponsive and with coffee ground-like material covering his chest.
• She called 911.
• He was transported back to the Emergency Department he had been to the prior evening where the following was found:
• A head CT Scan showed a very large intracranial hemorrhage with a huge left shift.
• Labs showed severely elevated coagulation studies with an INR > 4.0
• Keith was then transferred to another facility that was more equipped to handle the level of acuity with which he presented.
• 2 days later the patient’s wife withdrew care due to the extent of his brain damage.

What do you think? Does the nurse have liability in this case? See part 2 for my analysis as well as how the Code of Ethics ties to this case.

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Carol Alvin provided this guest blog. She is a legal nurse consultant at Alvinandassociateslnc.com. Carol spent all of her time in her 31 ½ years at the bedside where she had a passion for patient care but also a passion for teaching the nurses and residents that worked alongside of her. Sign up for her free report, 10 Necessary Facts You Need to Know When Reviewing a Chest Pain Case at www.alvinandassociateslnc.com.

Are you interested in writing a guest blog for legal nurse consultants? Contact Pat Iyer through the contact form on this site.