Nursing documentation in wound care is a key factor in determining liability

Nursing documentation

The medical record is an essential piece of evidence in any legal case alleging professional negligence against wound care nurses and others.

As you know, one of the purposes of the medical record is to reflect what nursing care was given to the patient. The entries speak to the quality of the care given.

The entries are supplemented by oral testimony at trial of those whose notations are in the medical record. A jury then decides if care was given that meets the standard of care in the situation or if the caregiver failed to meet his or her legal obligation.

The following 2020 legal court decision (Nixon v. The Brookdale Hospital Medical Center, Parkshore Health Care, LLC, Four Seasons Nursing and Rehabilitation Center, and the New York Community Hospital of Brooklyn, Inc.), illustrates the importance of nursing documentation and potential liability for patient injuries and death.

Summarized facts of the nursing documentation case

The 73-year-old female patient suffered from a myriad medical conditions:

  • Renal failure
  • Bowel and bladder incontinence
  • Tachycardia
  • Dementia
  • Anemia
  • Arteriosclerotic heart disease
  • Other co-morbidities
  • PEG tube

The patient also had many pressure wounds. The locations included the left hip, the sacral area, the right hip, and heels. These wounds got worse in size and severity during her many hospitalizations and ED visits. In addition, new ones developed during the course of her ED visits and hospitalizations.

Overall, the patient’s ulcers never improved and she eventually died.

The executor of the patient’s estate filed a lawsuit naming all the facilities that treated the deceased patient, alleging the hospitals did not uphold their standard of care in the treatment of the deceased patient. 

This failure, she alleged, caused the patient’s injuries and her death.

One of the medical facilities filed a Motion for Summary Judgment, stating that it did not breach its standard of care and that the alleged departure from the standard was not the proximate cause (legal cause) of the patient’s injuries and death.

Plaintiff’s expert opinion vs Motion for Summary Judgment

There were many legal arguments concerning whether the Motion for Summary Judgment should be granted or denied by the judge. But for the purposes of this blog, the argument by the plaintiff’s expert concerning the documentation of care provided proved indispensable for the plaintiff.

The expert opined that the medical facility that filed the Motion for Summary Judgment did not adequately turn the patient. This was supported by the “improper method of documentation” by the medical facility nursing, and other staff.

Specifically, the expert testified that the employees failed to provide measurements of the decedent’s pressure injuries and failed to identify their locations. This failure occurred despite the fact that several pressure wounds were noted on admission to the facility but not on discharge. 

Moreover, there was no nursing documentation of the assessment of those pressure wounds.

In addition, the expert focused on the documentation of two nurses who were responsible for turning and repositioning the patient before care was given.

While there was evidence in the record that some nurses properly documented turning and positioning the patient each time it was done, the two nurses’ documentation under scrutiny did not do so.

Rather, they “pre-filled” nursing documentation on turning and positioning the patient in the medical record. Such a practice is inconsistent with the standard of care and practice when regular intervals in care, such as turning and positioning, is needed.

Furthermore, for approximately 10 days, there were only two nights documented that the patient was turned. This infers, the expert continued, that these were the only two nights the deceased patient was turned during that period of time.

And, because the patient had many pressure injuries, it is likely it was impossible to prevent placing her on any existing wounds. As a result, more frequent turning and positioning should have been done, such as every hour rather than every two hours.

Such a schedule, the expert stated, would have prevented the worsening of the existing pressure injuries on the sacrum, left hip, and left shoulder.

Lastly, the expert noted that some of the deceased patient’s pressure injuries were stable or healing prior to her admission to this medical facility. Thus, the argument that the pressure wounds were unavoidable due to her medical condition cannot be supported.

In short, his opinion was that the lack of proper care for pressure wounds caused infections of those wounds, worsening them, and resulted in sepsis which ultimately caused her death.

Medical facility’s arguments

The medical facility’s arguments against the expert’s opinion pointed out, among other points, that the trial record reflected proper documentation by the nurses and care consistent with the nurses’ standard of care and standard of practice.

The nurses involved in the care of the patient testified orally and produced affidavits that they did provide care consistent with their documentation, as evidenced by their respective signatures or initials on the medical record sheets used for positioning and turning the patient.

Their expert also alleged the plaintiff’s expert made numerous misstatements of facts that led to unmerited allegations of a breaching of the standard of care.

The court ruled that although the hospital “met its burden” for the granting of a Summary Judgment, so had the plaintiff met her burden of raising a material issue of fact concerning the care of the patient.

Therefore, a granting of the Summary Judgment Motion could not take place because the plaintiff’s expert testimony must be submitted to the jury for its determination of liability or no liability.

What this case means for your practice

For those of you who practice wound care nursing in an acute setting, it is extremely important that your nursing documentation reflect the care that you gave when you gave it.

This means that no pre-filled flow charts, check off lists, narrative documentation done at the beginning or end of a shift, block charting (“7 a.m. to 3 p.m.”), and documentation prior to the time the actual care was given be used.

Although it takes more time, documenting care when given at the time given can prevent an allegation that the care did not occur.

Your facility’s nursing documentation policy and procedure should reflect this requirement. As you know, a facility policy and procedure can be introduced into evidence. 

If your care documentation follows its mandates, it will be helpful to you. If your care is unsupported by your documentation, it may result in liability.

If you are concerned about your facility’s requirements for documenting wound care, bring this concern to your Policy and Procedure Committee. It’s important to ensure turning and re-positioning of patients is consistent with current standards of practice for such documentation.

Your oral testimony in a professional negligence trial is important. You are legally and professionally obligated to document care completely, honestly, and factually. When a question arises as to what care was provided, medical record documentation is the first factor considered when deliberating liability. 

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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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