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Gaps in Care and Communication Lead to Patient's Death

Jane Smith thought respite care was the answer for her husband, Tom, while she was on vacation. What happened while she was gone spurred a lawsuit.

Tom Smith, 74, was admitted to an assisted living facility for two-week respite care and became severely dehydrated. He had a medical history of diabetes insipidus (DI) and a mild traumatic brain injury (mTBI).

Tom was pleasant, conscious, and oriented to person and place, but needed assistance with activities of daily living including toileting. He was bowel and bladder incontinent if unassisted.

Tom’s wife, Jane, informed the caregivers at the facility that they needed to not only pour water in a glass for Tom, but also to watch him drink it. Otherwise, he would forget to drink the water, even if the cup was sitting on the table right in front of him.

Tom’s primary care physician, Dr. Darren North, noted his history of diabetes insipidus and mTBI on Tom’s admission orders. Dr. North did not indicate that Tom’s DI was neurogenic versus nephrogenic or that Tom had an absent thirst sensation due to his mTBI. Dr. North’s orders included, “push a lot of water” and monitor intake and output.

Jane went on a vacation with family for two weeks. When she returned to the facility, she found Tom in bed unresponsive, in urine-soaked clothes and sheets. He was transported to a hospital where labs and diagnostics revealed hypernatremia, hyperkalemia, increased plasma osmolality, increased hematocrit, increased hemoglobin and increased urea to creatinine ratio. Tom passed away within 24 hours.

The Case Goes to Trial

Jane sued the facility and Dr. North for wrongful death. During the trial, the facility blamed Dr. North for inadequate admission orders and an incomplete medical history. Specifically, the nurses testified that they did not know what “a lot of water meant.” The nurses also testified that Dr. North did not communicate Tom’s absent perceived thirst sensation.

On cross examination, the nurses admitted that they never called Dr. North for clarification of his admission orders. The nurses also admitted that they failed to monitor Tom’s intake and output during the entire two-week period that Jane was gone. The nurses were unable to state how many times they filled Tom’s water container and they did not know how many times they helped Tom to the bathroom or how many times they changed Tom’s clothing or bedding during those two weeks.

Dr. North testified that he had written the same orders for Tom on other respite admissions to the same assisted living facility without any issues (Dr. North had been Tom’s primary care physician for decades). On cross examination, Dr. North conceded that his orders could have been clearer, but if the nurses had questions, they could have called him any hour of the day. Dr. North also conceded that he could have clarified Tom’s mTBI, namely his absent perceived thirst sensation. It was apparent during the trial that Jane liked Dr. North – she testified on cross examination that Dr. North was an excellent physician.

Dr. North’s nephrology expert testified that based on the hospital medical records, Tom was nine liters dry when admitted to the hospital.

The jurors appeared to favor Dr. North, but not the nurses. The jurors also appeared receptive to the testimony and opinions of Dr. North’s nephrology expert. They returned a verdict for $6.5 million against the assisted living facility. Dr. North received a defense verdict.

What Can We Learn?

Lines of communication between health care providers should be active, not passive. Health care providers should not assume that other care providers will contact them if they have questions about orders. Orders should be as clear and concise as possible, not vague and left to interpretation or assumption. Vague and unclear orders can negatively impact patient care and treatment. They can also lead to adverse outcomes.

Medical histories should be detailed, especially when it directly impacts patient care. A thorough medical history provides a complete picture of the patient to all who will be rendering care to the patient. If a comprehensive history is not documented, clinical symptoms may be missed or overlooked and necessary treatments may not be rendered. Even if the patient is “known” to a facility or provider, a complete medical history should be conveyed.

Care expectations should be precise. The expectations in rendering medical and nursing care should be clear and concise; otherwise, patients may not receive medically necessary care or they may receive erroneous care. Vague or imprecise care expectations can negatively and adversely impact patient care, treatment and outcomes.

Strong patient and family relationships matter. Building a trusted relationship with the patient and the patient’s family is important for continuity of care. Open communication lines with patients and their family members build trust and positively impact overall compliance.  

Presentation in front of a jury can impact the outcome. Kindness, sincerity, and empathy are paramount. Non-verbal actions are “heard” and seen. Know your patient and the patient’s record. This demonstrates care and concern versus seeing the patient as just a number. People relate to people, not numbers.

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