Hyperbaric oxygen therapy case: Liability can result from treatment inaction

hyperbaric oxygen therapy

Many of you have worked with wound care patients needing antibiotics and hyperbaric oxygen therapy.

In the 2016 Texas case of Gonzalez v. Padilla, the issue of whether the antibiotics or hyperbaric oxygen therapy were properly prescribed was a core issue in the case.

The patient was struck while riding his motorcycle and was taken to a university-based medical center with a broken lower right leg and a de-gloved heel.

An open external fixation procedure of his compound, comminuted fracture was successfully performed and a “halo type” fixation device was placed around the leg to hold the bones in place as the fracture healed.

The patient was also placed on IV antibiotics, including Gentamicin and Cefazonlin for a period of five days. In addition, he received daily wound care treatments.

The medical center’s records indicated his right leg showed “obvious evidence of continued blood flow … and no obvious necrosis beneath the heel tissue itself.”

Transfer to rehabilitation

The patient was transferred to a rehabilitation facility. When discharged from the medical center, his discharge orders required the Cefazonlin be continued for a period of 10 more days.

At the rehabilitation center, however, he received topical rather than oral or IV antibiotics. After a 12-day stay at the rehabilitation facility, he was transferred to another hospital for additional wound treatments, including hyperbaric oxygen therapy.

At his stay at the third facility, the patient did not receive oral or IV antibiotics. The hyperbaric oxygen therapy was to continue for three to four weeks, but the patient did not tolerate them well.

Even so, he asked for more treatments. But after five days there, he was discharged home with an open wound, the stabilization device still in place and with no comprehensive treatment plan.

Infection sets in

The patient received home health care after being discharged from the third facility. Nine days after his discharge, the home health service suggested he go to the emergency department for treatment of his leg. 

The ED physician diagnosed a serious infection in the leg and instructed the patient to return to the university medical center for treatment. The patient did so, but because of the presence of gangrene, his right leg was amputated below the knee.

The patient sued the two treating facilities after his discharge from the medical center, along with two physicians who cared for him at the two facilities.

The four defendants filed a motion to strike and dismiss the expert witness report supporting the merit of the patient’s case, which is required in any professional negligence case. The trial court denied the motion and the defendants appealed that decision.

Appellate court review and decision

The appeals court carefully reviewed and applied applicable case law to this specific case. Initially, the court opined the expert witness was qualified to be an expert.

Secondly, the court held the treating physicians breached their standard of care by not:

  • Protecting the patient from developing an infection, especially under high-risk conditions this patient faced.
  • Establishing and carrying out “an adequate and comprehensive plan of care” once the patient was discharged home.
  • Closely monitoring and following the patient with a “very serious limb-threatening infection.”
  • Keeping the patient for treatment in an appropriate facility and instead discharging the patient home without further treatment.
  • Considering a skin graft or other further surgery to close the wound.

As to whether these inactions caused the patient to lose his lower right leg below the knee, the court relied heavily on the expert witness report that “a more aggressive approach in treating … [the] condition would have prevented the infection or at least keep it from advancing to the extent that it did.”

The court upheld the trial court’s decision, allowing the patient to proceed with his case.

What does this case mean for you?

Although the case involved two wound care physicians and their respective employers, it has directions that can be helpful to anyone practicing wound care.

Some takeaways from this case for your practice include:

  1. Always provide wound care consistent with your applicable standard of care.
  2. Remain up to date with new wound care treatments, such as hyperbaric oxygen therapy.
  3. Carefully document a patient’s discharge condition and any recommendations for further treatment.
  4. As a wound care physician or advanced practice registered nurse (APRN), carefully consider if antibiotics are required for the patient’s condition and, if so, which ones and how they should be administered (e.g., oral, IV, topical).
  5. Do not discharge a patient with a high-risk wound.
  6. If you are employed by a healthcare facility, your employer or you also might be named as a defendant in a suit under the respondeat superior theory of vicarious liability.

Take our course on Nutrition and Wound Management.

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Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

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