Nursing Documentation
Mrs. Sullivan, a 62-year old patient, was admitted to the acute care setting for treatment of rheumatoid arthritis. The admitting note and history did not mention that Mrs. Sullivan had come into contact with infectious pulmonary tuberculosis in her job as a supervisor at a social services halfway house or that she had a history of testing positive for tuberculosis on the PPD tuberculin. The nurse’s admitting notes included the patient history of arthritis, stomach problems (GERD), and gastric ulcers, but did not mention her history of diabetes, kidney disease and exposure to tuberculosis. The patient exhibited no signs of tuberculosis when she was admitted. Admitting orders included medications for the arthritis and tests including PPD.
Four days after her admission, the nurse noted that the ordered tests, including the PPD, had not been done. The nurse verified this with Mrs. Sullivan, and the patient told this nurse that she always tested positive for tuberculosis on a PPD. She further stated that a chest x-ray was always ordered to determine the current activity of a dormant tuberculosis condition from her past occupational exposure.
The nurse charted on Sunday that the tests had not been done and also charted what the patient had said about her positive reactions to the PPD tests. Over the next ten days Mrs. Sullivan’s physician and two infectious disease specialists ran a variety of tests and treated Mrs. Sullivan with various antibiotics. The patient’s condition continually deteriorated, and a spinal tap was ordered, which revealed spinal meningitis. Mrs. Sullivan died 3 days later. Her family filed a lawsuit for negligence for not coming up with a timely diagnosis and her ultimate death.
Questions to answer:
- Did the lack of documentation in the admitting nurse’s assessment and notes affect the ultimate outcome of this case?
- Was there negligence on the part of the nursing staff in the care of this patient?
- Should the nurse who noted the failure to perform the ordered tests have done more than merely note that these orders were not completed? Does the fact that this was a Sunday impact your answer?
- How would you decide this case from your knowledge of legal implications and negligence?
