Legal Case Highlights Importance of Wound Care Documentation

wound care documentation

We have discussed the importance of nurse expert testimony in cases alleging professional negligence against you.

One blog addressed a breach of your standard of care when providing wound care.

A second reviewed the importance of your wound care documentation in the patient’s medical record.

This article takes a look at the 2016 case, Henson v. Grenada Lake Medical Center, to underscore both of these important points.

Case details

The female plaintiff was a patient admitted to a medical center because of the presence of diarrhea and other conditions. She was assessed a fall risk based on these disorders.

While being weighed on a standing scale, she fell, dislocating and fracturing her ankle. Staff wrapped her ankle and applied a plaster cast. The patient was transferred to another hospital for orthopedic care.

The patient underwent surgery at the orthopedic hospital. When staff there removed the cast, they noticed fecal matter on the splint and a blood blister on her leg. She was then transferred to a long-term care facility.

About 17 days after the surgery, the patient was transferred back to the orthopedic hospital with a staph infection in her wound.

Ten days later, she was transferred to a university hospital where her physicians noted a “wound breakdown with exposed hardware and necrotic tissue” in the wound care documentation.

Several days later, the patient underwent a left leg amputation below her knee.

Court proceedings

The patient filed a professional negligence case against the medical center and the university medical center alleging that the first medical center did not properly prevent her from falling and failed to provide proper wound care.

This failure led to an infection and the ultimate amputation of her lower left leg.

By agreement of the parties, the university medical center was dismissed from the suit, leaving the first medical center as the sole defendant in the case.

The medical center filed a Motion for Summary Judgment. The basis of its Motion was that the patient’s only nurse expert witness did not address — and was not competent — to testify to the patient’s injuries and the supposed negligent treatment by nursing staff.

The nurse expert witness’ affidavit contained the following general statements:

  • The hospital medical staff failed to provide adequate safety measures to prevent the patient’s fall.
  • The nurses failed to meet recognized standards of care and professional standards of practice.
  • The nurse’s opinions are based on a review of the medical records, her academic credentials, knowledge, skill, experience and expertise in the field of nursing.
  • The nurse’s opinions are based on a reasonable degree of certainty as it relates to nursing negligence.

The trial court granted the medical center’s Motion because it ruled that the nurse expert’s testimony did not speak to the causation of the patient’s injuries. Therefore, the testimony did not support a breach of the standard of care by the nurses.

The patient appealed that ruling.

Appellate Court decision

The court carefully reviewed state law applicable to the case.

In Mississippi, it began, a nurse is not qualified to testify about medical causation, an element essential to proving a professional negligence case.

Therefore, the patient’s expert is not competent to testify that the negligent nursing care caused a staph infection, “much less that it ultimately required the amputation of” the patient’s lower leg.

The patient argued that the nurse expert’s opinion was only to establish that the nursing staff’s negligence caused the patient’s fall. But the court opined that this position still leaves out testimony about the medical causation of the patient’s injuries.

Moreover, the court continued, the nurse expert’s testimony does not specifically state what sort of “safety measures” the medical center failed to provide. Plus, the testimony does not convey what standards she referred to and how they were breached.

Because the nurse expert did not explain the how, when, and why of the situation before the court, the testimony could not create a genuine issue of material fact that would defeat the Motion for Summary Judgment.

The court affirmed the decision of the trial court.

Your takeaways from this case

The patient in this case suffered an injury that may have been avoided with proper care.

There is no doubt negligent care occurred somewhere and somehow during the patient’s many hospitalizations. One does not ordinarily discover fecal matter on a splint. Nor is a blister ignored, especially on a leg that has been casted.

Moreover, the presence of a staph infection speaks to the possibility of negligent wound care.

Even so, the patient’s nurse expert simply failed to provide the needed details to overcome the medical center’s Motion for Summary Judgment.

Why this happened is unclear, but it bears noting that if you undertake the role of a wound care expert witness, you need to specifically testify, not only to the standards of practice and care that were breached but also how those standards were breached.

Wound care documentation matters

The nurse expert did state that she reviewed the patient’s medical records. It is not known, but it may be that those medical records were devoid of specific wound care documentation. 

If so, this is another example of how important the detailed documentation of your wound care is – not just because it is the professional thing to do.

In the event that a lawsuit is filed and your care is at issue, honest, complete, accurate, and factual wound care documentation is essential.

Last, this case illustrates a failure to protect a patient’s ability to seek redress for her very serious, very permanent injury — an amputation of her leg. Had the requisite legal aspects of her case been met, she would have had a chance to win.

Don’t be part of such an ending. Provide and document your care consistent with your legal and ethical mandates. Do the same in your role as an expert witness in wound care. 

Become a wound care specialist with our course today!

wound care

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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