Sample Case Evaluation Reports - Geriatric Expert Witness

 

 

Please click on the titles below to go to the corresponding sample Case Evaluation Reports.

Elderly Nursing Home Patient Develops Urine Infection, Severe Dehydration Untreated and Dies.

At age 83 this patient was in the Nursing Home for rehabilitation from fractured ribs and for “generalized deconditioning.” She was receiving breathing therapy and bronchial dilator drug therapy. On 1/1 she began to cough, and had some wheezing. This progressed and on 1/6 she had a chest x-ray which showed no acute (pneumonia) changes.

On 1/8 she developed watery diarrhea and Dr. S prescribed Kaopectate. This was good care. The nurse noted: “No signs of dehydration.” Persistent diarrhea with low fluid intake can cause severe dehydration, and elderly patients are at higher risk. She also was receiving the very potent diuretic (“water pill”) Lasix at 20 mg.day. This was never stopped. That would dehydrate her more, and more quickly.

The diarrhea improved from 1/9 – 1/14. Her appetite decreased dramatically from 1/8 until 1/18 where she only consumed 25% of her meal, and from 1/18 – 1/19 she refused all food and liquids. The nursing sheet section “Health Conditions: Indicators of fluid status” is totally blank. The Physician never ordered any fluid “Intake and Output” to be recorded, and the Nurses never initiated that basic evaluation, even after they documented a six pound weight loss from 1/8 until 1/17 and advised Dr. S of that significant fact on 1/17.

She had been receiving the potent broad spectrum antibiotic Ceftin for approximately 10 days, from 1/6 – 1/16. This antibiotic, like many others can cause a severe form of diarrhea caused by the overgrowth of the bacterial germ Clostridia difficile in the large intestine. This was never considered, tested for, or specifically treated.

On 1/17 Dr. S saw the patient and noted that: “She had decreased approximately 10 pounds from previous weights.” He noted good skin turgor (evidence against severe, but not mild, dehydration). Her abdomen was soft and not distended. Evidence against a perforated appendix or gangrenous intestine. He wrote: “observe her closely for any other problems.” But that same day he wrote an order: “Do Not Resuscitate” that allegedly her son was aware of. Why was that done?

From 1/12 until 12:30 p.m. on 1/19 no nurse ever checked her pulse, respiratory rate, blood pressure, or temperature (vital signs). That is negligent care by the Doctor and nursing home, as well as its employees. This is especially flagrant because of her six or ten pound weight loss, severe lack of appetite, catheterized urine specimen showing “dark cloudy amber urine with sediment” on 1/17 at 2 p.m., consistent with serious dehydration and infection (confirmed by laboratory testing: nitrite positive and 30 white blood [pus] cells seen per microscopic high power field). Dehydration promotes urinary tract infection by decrease washing out the germs. The blood white blood count was slightly elevated to 14,500, but there were 13% Band forms, seen with serious infections. And on 1/17 blood kidney creatinine test was normal at 1.7 (consistent with no serious chronic kidney disease or kidney failure), but the BUN (Blood Urea Nitrogen) kidney blood test was significantly elevated to 42 (normal is 5-22), diagnostic of significant and serious dehydration.

All those tests Dr. S ordered were faxed to him that day, and he negligently did nothing. He did NOT write an order to “force oral fluids,” start an intravenous, monitor “Intake and Output,” nor to check her vital signs, not tested for five days, as noted above. This is not “close observation”. This is gross neglect.

On 4/18 the Nurse noted: “Patient remains in bed, still not feeling well, patient has red raw butt from diarrhea, will fax note to M.D..” Her appetite remained poor, and the diarrhea continued to dehydrate her.

On 4/19 the Nurse noted: “Not feeling well, state lower abdomen has pain today, patient has UTI (urinary tract infection), Dr. S has not ordered antibiotic for UTI yet. Referred labs to M.D. today.”

By 12:30 her respiratory rate increased to 40 which is two to three times normal. And “Patient voiding only small amount urine. Continues to have loose BM (bowel movement)….patients condition has really deteriorated.”

AT 2:15 p.m. she had a respiratory rte of 50 and “stated she couldn’t breathe.” Nasal oxygen was started. Still no I.V. (intravenous) was begun. No one was directly encouraging her to drink liquids.

Elderly patients lose the sense of thirst, especially when ill. With infections, they often do not respond to temperature rises (although no one took her temperature for one week).

Her heartbeat was very irregular, “Patient did c/o of SOB (shortness of breath) and this is very unusual for this patient.”

At 3:15 p.m. Dr. S finally ordered her to be sent to the Emergency Room where she arrived at 3:40 p.m. There the blood showed that the creatinine had risen to 3.0 (from severe dehydration and infection) and the BUN was 81 for the same reasons. Her arterial blood, oxygen level was normal, but the carbon dioxide level was decreased to 28 (normal is 32-48) from hyperventilation to try to eliminate the acid build-up from her severe urinary tract (kidney and bladder) infection. The white blood count was now 33,300 (normal is 5,000-10,000) and the “bands” were grossly elevated to 31%: overwhelming infection.

At 5:30 p.m. the Emergency Room Doctor ordered intravenous fluids at 125cc (4 ounces) per hour. That is grossly inadequate for such a severely dehydrated patient. This order was written two hours after she arrived so ill. Why was it delayed? The intravenous Cipro was ordered at that delayed time. But it appears that the Nurse was not able to start the I.V. at 6:05 p.m. (1805), she began to vomit at 6:10 p.m., became very short of breath turned blue around her mouth at 6:15 p.m., they verified the “DNR” status and they let her die. Dr. Z pronounced her dead at 6:10 p.m.

After three hours in the Emergency Room she died. Was an autopsy done?

In my opinion her death was preventable and was caused by the negligence of Dr. S and the nursing home for all the reasons stated above. She was allowed to become severely dehydrated over one week, and the last two days she was obviously very sick from dehydration and her UTI and it was not treated despite all the obvious signs, tests, and they still failed to do all the “observation” the standards of care would require.

Prior to this illness she was awake, alert, ambulatory and otherwise stable, and would not have died at this time.

The Emergency Room Physician, corporation and employees were negligent for their delays which, in my opinion, would have had some chance for success if aggressive intravenous fluids and antibiotics would have been immediately started upon arrival, since they knew she was coming and presumably Dr. S would have called ahead and in fact, the note says “Discussed with Dr. S.” Who discussed what with whom, when and when did the “DNR” issue arise for the E.R. and why? The E.R. records notes that the E.R. Physicians were: Dr. T and Dr. M. Who did what and when?

I would suggest trying to supply the answers to my questions, and then authorize us to have these records reviewed by Experts in Infectious Disease, Geriatric Medical experience, and Emergency Medicine, as well as a Nurse with Elder Care Experience.

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Debilitated Nursing Home Patient Given Overdose of Non-ordered Anti-coagulant (“blood-thinner”), Hemorrhages to Death.

This patient was age 73 and living in a nursing home. She suffered from chronic pain caused by arthritis and MS (multiple sclerosis). She was bedridden and often refused to move in bed or get out of bed. Her family had a DNR (Do Not Resuscitate) order.

She had chronic constipation for which she received stool softeners, bowel stimulants and enemas. Her use of narcotics (OxyContin) would cause or contribute to her constipation. Sometimes her pain would be controlled by a placebo (nonactive “fake” medication) to lower her dose of narcotics, which may have been contributing to her hallucinations, too.

Her urine was consistently concentrated (color, odor and high specific gravity) consistent with chronic dehydration. Also contributing to dehydration: their failure to adequately hydrate her by frequent offerings of water which would be substandard care and also increase the risk of a urine infection, which she developed and was treated. She was also incontinent.

Overall, her care was reasonably good, better than most Nursing Home records I have seen.

On 11/27, because of her recent onset of delirium, she was ordered to have a head CT scan.

This showed a “chronic infarct (old stroke) on the left side…with a question of a small hemorrhage.” This was repeated on 12/7 and showed no change: “No evidence of acute infarct or bleed.”

Because of her history of a previous heart attack, she was properly receiving the low dose (81 mg) aspirin therapy to reduce the risk of another heart attack. This also protects her brain from thrombotic (blood clot) strokes.

She developed abdominal pain and alteration of her mental status (more lethargic and irrational), and was hospitalized on 12/8 and died on 12/9. She had some lower intestinal bleeding felt to be from diverticular disease (outpouchings of her large intestine, which can erode a blood vessel or become infected and even perforate). Her abdomen was generally soft, against an acute perforation with peritonitis (widespread abdominal infection).

Initially her vital signs were that her blood pressure and pulse were normal and her respiratory rate was slightly elevated to 24. I have not seen any follow-up records or therapy. Her skin had “multiple ecchymoses” (bruises) consistent with bleeding into her skin. On 12/7, her BUN (kidney blood test) was elevated to 33 but her creatinine (other kidney blood test) was normal at 0.6. This disparity is consistent with acute dehydration and/or acute bleeding with the protein from her blood being absorbed and overwhelming her kidneys’ ability to excrete it all.

Her hematocrit (HCT) was low at 31.1 on 12/8, consistent with anemia. The platelet count (clotting particles produced by bone marrow) was elevated at 573 (two times normal) consistent with an acute bleeding situation.

She did not receive any anticoagulation in the nursing home. There is no record of any Coumadin (warfarin) (a pill) ordered. HOWEVER, on 12/7 the PT (prothrombin time) test for the effect of Coumadin was markedly and dangerously elevated to 38.9 (three times normal) and the more modern test for the same effect, the INR, was greater than or equal to 7.5 (7.5 times normal). Also, the PTT (partial thromboplastin time), which monitors another clotting factor elevated from the use of the injectible anticoagulant Heparin (and Levonix), which could also become elevated from a massive overdose of Coumadin, was 95 (3.5 times normal).

It takes at least three to four days to achieve the PT and INR elevations from Coumadin. Therefore, I conclude she received that drug at the Nursing Home from negligence, or in an attempt to murder this patient (possibly an attempt of euthanasia). On 11/25 at 7:30 a.m., the Nurse’s note by #1 states: “Patient states: ‘How come I woke up alive. I was not supposed to. The Nurse in the night gave me a little white pill that would make me die.’” Was this a hallucination or a deathbed confession??

No autopsy was performed. If her body was not cremated (and preferably embalmed), an exhumation autopsy could be performed (we have Experts available), and if she had extensive internal hemorrhage from excessive anticoagulation, that visual evidence should be available. The FDA and manufacturer should be consulted to see if Coumadin can be tested postmortem too.

Based on the above, I must conclude that she was given a massive overdose of Coumadin for which she had no order for, or any doses noted on her medication record at the nursing home.

It may be helpful to obtain a complete copy of the hospital records from her 12/8 to 12/9 stay. I cannot tell if she went into shock (consistent with hemorrhage), and if it was not treated, since I am missing most of those records. Nor can I tell if Dr. #1 noted the abnormal laboratory test of 12/7 before her demise on 12/9 at 4:30 a.m. He should have seen it and also been called by their laboratory as an emergency “flag.”

The laboratory would be negligent if they did not call that problem to the attention of her Nurse and/or Doctor. The antidote (vitamin K and fresh blood plasma) could have corrected that blood coagulation problem in a few hours, and combined with transfusions could stabilize the patient. Also Dr. #2, a Consultant, called to see her for bleeding, on 12/8, also had a duty to check that test result from 12/7. He suggested “transfusion as needed.” Were any given?

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Confused, demented, sedated, disoriented 80 year old patient was hospitalized for surgery for a broken (fractured) hip, and after surgery was not properly restrained, fell out of bed, and fractured her other hip.

According to the records, the patient was 80 years of age, tripped at home, and was admitted to the hospital with a fractured left hip. After stabilization, she was taken to surgery on May 8, by Dr. #1. She had a resection of the femoral head that was fractured and replacement with a prosthesis. This was with the "endoprosthetic bipolar replacement." According to the x-ray reports, the operation was properly done.

Following this operation, the patient had difficulty with her lungs and had to be intubated (an endotracheal tube placed in the windpipe). A Pulmonary consultant, Dr. #2, managed that aspect of her care properly.

On the evening of May 8, at 20:30, the nurses' notes show that the patient was resting quietly and "wrist restraints in place to bilateral wrists, circulation intact and unimpaired." A similar nurses' note was recorded at 21:00, at 21:15, and at 22:15, just before the patient was transferred to the surgical intensive care unit. I was unable to find any physician's order for soft wrist restraints during this part of her care.

Some hospitals have standing orders (automatic routine procedures) that nurses follow, or have automatic nursing standards that allow nurses to apply soft wrist restraints when indicated. In some hospitals, they can apply the soft wrist restraints, but it then requires the physician to be contacted for an order to be written.

In addition to the use of soft wrist restraints, which is quite restricting, patients can also be placed in a Posey jacket, which is like a straight jacket with the arms freed, and the jacket is tied to the bed from behind. This allows the patient limited mobility, depending upon how tight the Posey restraint is pulled down to the bed.

When patients are confused, the hospital is required to protect the patients from harm, which includes falling out of bed, or climbing out of bed and falling thereafter.

According to the records, the patient was doing well within the few days following the hip operation.

The first orders for wrist restraints that I can find in the records occurred at 2:59 a.m. on May 14. It says, "restraints -apply: soft ties to wrist - prn (as indicated). Follow restraint protocol". This was the telephone order of Dr. #3. Then, on May 14, at 9:14 a.m., there is a further order to restrain with the soft wrist restraints, which follows a hospital format, as noted on the restraints order dated May 14, at 08:45. It allows the nurses to use their judgement to release the restraints if the behavior checked off is absent. The behavior checked off here was to use the restraints during "episodes of confusion resulting in potential or actual injury to self. . ."

In the doctors' progress notes from May 13, it appears to state, "realizes her confusion today." On May 14, it notes, "very confused. Fell last night. X-rays ordered." That x-ray documented a fracture of the right hip, and she was properly taken to surgery by Dr. #1 on May 14, for an open reduction and internal fixation of the intertrochanteric fracture of the right hip. A hip screw and plate were used to reduce the fracture and maintain it in position. X-rays confirm that the operation was correctly done.

Usually, elderly patients are more confused at night, and one of the procedures utilized is to leave a night light on in the room. I cannot tell if this was done or not from the records.

Furthermore, the side rails need to be elevated and the bed placed at the lowest level so that if the patient should get out of bed or fall out of bed, their fall to the floor is reduced. It appears from the records that the side rails were elevated and the bed placed in the lowest position.

According to the nurses' notes, on May 11, the patient was noted to be confused and disoriented at times. This was 16:00. At 20:00 (8:00p.m.), it says, "confused -- most of the time."

On May 12, at 8:00 a.m., noon, and 4:00 p.m. (16:00), the three recordings under the "neurologic" section show that the patient was "confused, disoriented to place and time." Despite that, no Posey restraint or wrist restraints were requested by the nurses, or ordered by the physicians.

Under the "psychosocial" section of the patient care notes that are typed, at 16:00 on May 12, it says, "Affect: confused most of time." On that day, the patient only took 25% of her dinner, less than usual.

In the handwritten patient care notes, at 20:00 on May 12, it says, "confused to time and place." On May 13, at midnight, 4:00 a.m., 8:00 a.m., and noon and at 20:00, it says the patient was confused, she was disoriented. On May 13, the patient was incontinent of urine at times, which is the first note of such a problem in the records.

Under the "musculoskeletal" section, on May 13, at 20:00, it says, "patient confused and crosses legs." This is contraindicated following a hip operation. In the "psychosocial" section for that entire day, it notes the patient was confused.

Despite all the above, no restraints were requested or ordered.

On May 13, at 22:59, under the "safety" section, it says, "bed low/locked, bell in reach, side rails up, instructed to call for assistance." This is by a Nurse whose initials are #1. However, you cannot instruct a confused patient to call for assistance.

Under the handwritten patient care notes on May 13, at 09:00, the nurses state that the patient was "pleasantly confused." She received physical therapy. She was short of breath (SOB), and oxygen was applied. This was a new complaint. At 00:00, it says that she was confused. She had no complaints of pain at that time.

That patient care note, as all of them in the records, have a stamper plate in the upper right hand corner. However, the next page, which appears to be a continuation of the above notes, even though the bottom two lines on the previous page are blank, does not have a patient stamp on that right upper corner. This should be investigated.

Then, at 01:20, it notes that when the rounds were made, the patient was found nude sitting near the bathroom door. It notes the side rails were still up. With the assistance of two people, she was able to ambulate without complaints of pain at that time. They noted that the right and left lower extremities were intact neurovascularly. They noted there was no shortening or external rotation of the legs, which is usually seen with a hip fracture.

They notified the Physician at 01:45, and orders were written for soft restraints to be used as needed. At 02:00, it notes that the soft elastic restraints were applied.

At 02:45, they noted that the patient was out of the soft restraints and somehow was able to rise up or pull herself free from the restraints, and she was found pulling her torso over the side rail of the bed. The restraints were reapplied, and the patient was complaining of pain in the right hip. Despite that, apparently no physician was notified until later that morning when the hip x-ray was obtained and showed a fracture of the right hip.

In my opinion, since this patient showed episodes of increasing confusion in the previous days, they should have notified the Pysician who should have ordered a Posey restraint or soft wrist restraints. As an alternative, they could have arranged for a sitter, by the hospital or the family, to be at the patient's bedside continually to protect the patient from injury. None of this was done, and in my opinion, that is a departure from the accepted standards of care of Hospital #1, as well as the attending Physicians. All the physicians seeing this patient, including the orthopedic surgeon and the others, had a duty, in my opinion, to note her confusion and order appropriate restraints. Furthermore, the nurses had a duty to contact the treating physicians, who may not have read the Nurses' notes, and notify them that there was a problem and request that an order be written. Also, they could institute restraints on their own, and then request a physician's order to support that action of the n urse.

Based upon their documentation, it would appear the patient did not fracture her hip when she climbed out of bed at 01:20, but after the wrist restraints were not properly applied, the patient injured her hip during that subsequent episode that was documented at 02:45.

The patient was also sedated and receiving narcotic pain medication. That, plus her age of 80, plus her history of dementia, lung problems, previous fainting episode that required hospitalization during Easter, and her fall at home that precipitated the admission with the hip fracture, all should have required the patient to be properly restrained, particularly in the evening, when these patients are prone to become more disoriented. She had increasing urinary incontinence, was eating less, and was more confused. All this is well-documented in the records.

In my opinion, all the above would require appropriate bed restraints, which should have been at least the Posey jacket restraint. In my opinion, the proper use of that jacket restraint, or the proper use of soft wrist restraints, would have prevented the subsequent fracture from occurring.

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Through discovery, obtain all of the standing orders of these physicians, as well as the hospital standing orders and nursing standards that the Hospital promulgated and were in effect during that time, with regard to the use of restraints.

The Defense would argue that the fracture was identified, she underwent successful surgery, and it only extended her hospital stay a small amount of time. Furthermore, this was paid for by Medicare insurance.

It would be important to document the current status of the mobility of the patient. She was going to be transferred to a skilled Nursing care facility, and was she ever able to be fully ambulated, having two hip fractures?

Because of her age, I would suggest you have a "day in the life" film taken to show the current status of the patient. I would also urge that a fast-track for trial be utilized because of her age and associated diseases.

In this case, I suggest that we first obtain the services of one of our Nursing Experts and then one of our Orthopedic Surgeons. You will have to conduct some discovery with regard to the standards I noted above, as well as deposing the Nurses that were in attendance during that night of May 13 and early morning hours of May 14.

We have these Experts available through our independent consulting staff.

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