by Wayne Wenske, Senior Marketing Strategist, and
Karen Werth, MBA, CPHRM, Senior Risk Management Representative
Presentation
On December 27, a 74-year-old woman came to a local hospital emergency department (ED) with acute lower back pain. Her history included breast cancer with right mastectomy 14 years earlier; coronary artery disease; thyroid disease; hypertension; hyperlipidemia; and depression. Upon examination, she was diagnosed with sacral fractures and admitted to the hospital.
On January 8, the patient was discharged and transferred to a senior living center for monitoring, rehabilitation, and follow-up with orthopedics as an outpatient. She was also scheduled for physical and occupational therapy to improve her balance, mobility, and self-care skills.
Upon discharge from the hospital, the patient was diagnosed with sacral insufficiency fractures and bilateral sacral fractures; type II diabetes mellitus with hemoglobin; metabolic acidosis with low carbon dioxide secondary to saline infusion; urinary retention and incontinence; and constipation. Prescriptions included metformin and tramadol.
Physician action
Internist A admitted the patient to the senior center and ordered new labs, including CBC, CMP, prealbumin, and blood glucose. Internist B obtained a history and exam; he documented the patient’s mental status as “oriented to person” and her neurological exam as “alert and oriented x3.”
On January 10, the patient reported intense pain. Internist A ordered a fentanyl patch which was started the next day, January 11. On January 12, the patient was noted as having new onset acute abdominal pain and hypotension. These conditions were attributed to the medications.
Internist A documented the patient as being “alert and oriented x2,” but confused, agitated, and expressing suicidal ideation. The patient’s husband attributed the suicidal ideation to the fentanyl. Internist A ordered a KUB x-ray for the abdominal pain and psychiatry consult.
The x-ray was negative, and orders were given for urinalysis, culture and sensitivity, a new CBC, and a subsequent CBC and CMP to be performed on January 20. The patient’s record did not show whether the psychiatry consult was obtained.
On January 16, the patient complained of pain (7 out of 10) and was confused, screaming, disoriented, and refusing to eat. For the next several days, the patient was noted as having an altered and increasingly disoriented mental status. On January 18, the center’s assistant director of nursing was notified of the patient’s status and the increased difficulty for the nurses in managing her care.
On January 19, Internist B documented that the patient was stable, but diagnosed two new conditions: leukocytosis and oral candidiasis. The CBC showed a WBC of 14.9. The remaining test results were still outstanding.
The next day, the patient’s husband called the facility and spoke to a nurse. He said he believed his wife had a urinary tract infection (UTI) and he wanted her to receive antibiotics. Internist B would not prescribe antibiotics until the urinalysis and culture and sensitivity test results were received.
On January 21, after not receiving test results, Internist B ordered a new urinalysis. The patient was documented as lethargic with increased confusion. Her blood pressure was 78/52 mm Hg. Internist B also ordered a prescription for ciprofloxacin 500 mg, which was given to the patient that day.
On January 22, the patient had an acute change in blood pressure and mental status. Internist A documented that she had worsened and altered mental status, new onset UTI, and sepsis. Internist A also documented that the patient’s systolic blood pressure was in the 40s, but her last recorded blood pressure was 91/76 mm Hg. The patient’s mucus membranes were also noted as dry.
Due to steep decline in her condition, the patient was transferred back to the hospital. The patient’s husband told the admitting physician that his wife had been in a steady decline for two weeks and that she had an untreated UTI. Admission notes describe the patient as being confused, only partially responsive, and showing severe behavior changes. She was diagnosed with septic shock, hypotension, acute renal failure, metabolic acidosis, and acute respiratory failure with hypoxia.
On February 9, the patient died. The death certificate listed the cause of death as aspiration pneumonia.
Allegations
A lawsuit was filed against Internist A and Internist B. The allegations included failure to timely diagnose and treat a UTI during the patient’s stay at the senior living center from January 8 to January 22. A lawsuit was also filed against the senior center.
Legal implications
Internal medicine consultants were critical of the care provided in this case. It was noted that the defendants ignored serious changes in the patient’s mental status and signs of infection, including an elevated white blood cell count. They also showed no urgency in evaluating the patient or following up with lab test orders.
Lack of urgency was noted by almost all the consultants, along with lack of documentation, lack of assessment, failure of patient advocacy, and failure of the nursing staff to comply with physician orders.
There is documentation that the patient’s mental status continually worsened, and she was refusing to eat. Consultants felt these notes should have triggered more urgent workup and transfer to an acute care setting. Documentation was also noted as being redundant, copied from earlier entries, and templated. Phrases used in the notes were also ambiguous and contradictory. For example, on the day the patient was transferred back to the hospital, a templated note described the patient as “well-appearing.”
One consultant for the plaintiff stated that had the patient been transferred to an acute care hospital as late as January 19, there would have been time to treat the patient’s UTI before it progressed to sepsis. However, the UTI was not diagnosed or treated in a timely manner and the patient ultimately died because of the infection spreading to her lungs and causing pneumonia.
Disposition
This case was settled on behalf of Internist A and Internist B. The outcome of the case against the senior center is not known.
Risk management considerations
In this case, there were several instances where delays in orders, poor documentation, and breakdown in communication and patient care occurred.
Due to the patient’s suicidal ideation, an order for a psychiatry consult was placed but never performed and a second emergent order for a consult was placed. Physician orders for tests were not timely performed, which resulted in several days passing between the time tests were ordered and results received, including a CBC and a urinalysis with culture and sensitivity. This led to a delay in diagnosis and treatment of the UTI.
When tests are ordered in a facility setting, the ordering provider should be attentive to timelines and question any delayed results.
Documentation was also a weakness in this case. Multiple contradictions were seen in the physician’s notes due to overuse of EHR templated text. One note said the patient had “new abdominal pain with nausea and vomiting” but was contradicted elsewhere in the documentation, which stated “negative for abdominal pain.” In addition, copying text or “cloning” from one note to the next was seen.
When using preformatted text or templates, it is recommended to review the entire template and edit entries as necessary to ensure the record accurately reflects patient status and clinical care delivered.
High quality documentation and reporting are necessary to enhance efficient, safe, and individualized patient care. Quality documentation should be factual, complete, consistent, current, and organized. Documentation should include what the patient says or does, the assessment, and any meaningful communication between providers.
Lack of communication further complicated this case. Staff did not always document why they contacted a physician, and they did not always notify a physician of significant findings, including the patient’s breakthrough pain, need for assistance with all ADL, and altered mental status.
It is recommended that facilities and practices have explicit policies and procedures in place for handling test results. These protocols should clearly define appropriate timelines for receipt of results, and what circumstances should prompt staff to immediately communicate with a physician concerning a patient’s condition. These may include urgent, abnormal, and concerning findings.
Although not an issue in this case, it is important that staff members have a clear understanding of lab report standards and what constitutes an abnormal result. If the staff member does not understand a lab report or a test, the policies and procedures should instruct the staff member to request clarification from the physician, lab, or hospital. Require staff members to regularly review protocols and acknowledge their understanding of the rules in writing.
Lack of urgency, combined with poor documentation and communication, contributed to the delay in diagnosis and treatment in this case.
Wayne Wenske can be reached at wayne-wenske@tmlt.org.
Karen Werth can be reached at karen-werth@tmlt.org.
