MD3 Module


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You work in a gynecological office, and your office has been asked to participate in a women’s health fair. The focus of the fair is health promotion.

  • Preventative screening
  • for female reproductive disorders is vital to identify and treat rapidly to produce the best patient outcomes. Preventative screening includes mammogram and Pap smear and should be performed based on recommended age and associated risk factors. To promote preventative screening, your office will be creating brochures to distribute at the health fair.


    Design a women’s health brochure by choosing one of the female reproductive disorders covered in this module. In the brochure, include the following:

    • Overview of the disease including disease process, signs and symptoms, and risk factors
    • Preventative screening

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    • Diagnostics tests
    • Treatment
    • Multidimensional nursing care interventions

    please give References 

    The fifteen year-old patient was scheduled for surgery on the right

    side of his brain to remove a right tem-
    poral lobe lesion that was believed to be

    causing his epileptic seizures.
    The surgery began with the sur-

    geon making an incision on the left
    side, opening the skull, penetrating the
    dura and removing significant portions

    of the left amygdala, hippocampus and
    other left-side brain tissue before it was

    discovered that they were working on
    the wrong side.

    The left-side wound was closed,
    the right side was opened and the pro-

    cedure went ahead on the right, correct
    The error in the O.R. was revealed

    to the parents shortly after the surgery,
    but only as if it was a minor and incon-

    sequential gaffe.
    The patient recuperated, left the

    hospital, returned to his regular activi-
    ties and graduated from high school
    before his parents could no longer deny

    he was not all right. After a thorough
    neurological assessment he had to be

    placed in an assisted living facility for
    brain damaged individuals.

    When the full magnitude of the
    consequences came to light a lawsuit

    was filed which resulted in a $11 mil-
    lion judgment which was affirmed by
    the Supreme Court of Arkansas.

    A circulating nurse has a le-
    gal duty to see that surgery
    does not take place on the
    wrong side of the body.
    The preoperative documents
    failed to identify on which side
    the surgery was to be done.
    It was below the standard of
    care for the circulating nurse
    not to notice that fact and not
    to seek out the correct infor-

    December 13, 2012

    Operating Room: Surgical Error Blamed, In
    Part, On Circulating Nurse’s Negligence.

    Surgical Error Blamed, In Part, On

    Circulating Nurse’s Negligence

    The Court accepted the testimony
    of the family’s nursing expert that a

    circulating nurse has a fundamental
    responsibility as a member of the surgi-
    cal team to make sure that surgery is

    done on the correct anatomical site,
    especially when it is brain surgery.

    The circulating nurse is supposed
    to understand imposing terms like se-

    lective amygdala hippocampectomy
    and know the basics of how it is sup-

    posed to be done.
    Hospital policy called for the sur-
    geon, the anesthesiologist, the circulat-

    ing nurse and the scrub nurse or tech to
    take a “timeout” prior to starting a sur-

    gical case for final verification of the
    correct anatomical site.

    The circulating nurse should have
    available three essential documents, the
    surgical consent form, the preoperative

    history and the O.R. schedule.
    The full extent of the error, that is,

    a full list of the parts of the brain that
    were removed from the healthy side,

    should have been documented by the
    circulating nurse, and failure to do so

    was a factor that adversely affected the
    patient’s later medical course, the pa-
    tient’s nursing expert said. Proassur-
    ance v. Metheny, __ S.W. 3d __, 2012 WL
    6204231 (Ark., December 13, 2012).

    January 2013 Volume 21 Number 1

    Inside this month’s
    Issue …

    January 2013

    New Subscriptions
    See Page 3

    Operating Room/Circulating Nurse – Nursing Home Admission
    Labor & Delivery Nursing/Pitocin/Fetal Monitor
    Labor & Delivery Nursing/High Risk Patient/Fetal Monitor
    Medication Error/Nursing Negligence – Correctional Nursing
    Age Discrimination – Race Discrimination/Minority Nurses
    Skilled Nursing/Blood Draws/PT/INR/Reporting To Physician
    Flu Immunization/Public Health Emergency – Nursing Assessment
    Nurse Practitioner/Pre-Signed Prescriptions – Threat Of Violence

    Legal Eagle Eye Newsletter for the Nursing Profession January 2013 Page 2

    Labor & Delivery, Pitocin, Fetal
    Monitors: Court Finds Evidence
    Of Nursing Negligence.

    T he mother was admitted to the labor and delivery unit at 10:10 p.m. for
    induction of labor.
    The baby was delivered vaginally at
    5:27 p.m. the next afternoon with the um-

    bilical cord around her neck. She did not
    start breathing on her own for almost seven

    minutes and then began having seizures.
    A pediatric neuroradiologist, who per-

    formed ultrasound scans on the child’s
    brain and who would later submit an expert

    report for the family in their lawsuit
    against the hospital, related the child’s
    problems to asphyxia consistent with brad-

    ycardic events prior to her delivery.
    The Court of Appeals of Texas accept-

    ed reports prepared by the family’s experts,
    an ob/gyn physician, a labor and delivery

    nurse and the pediatric neuroradiologist
    which pointed directly at the negligence of
    the labor and delivery nurses.

    Family’s Medical Expert

    When Cytotec has been used for cervi-
    cal ripening followed by IV Pitocin for

    induction of labor, the labor and delivery
    nurses have the responsibility to maintain

    readable tracings of the fetal heart tones
    and the maternal contraction patterns. The

    nurses should not start or continue Pitocin
    when there are non-reassuring fetal heart
    tracings, when the contractions cannot be

    monitored or with uterine hyperstimula-
    tion. The physician must be notified of

    non-reassuring fetal heart tracings.
    Family’s Nursing Expert

    When Pitocin is in use the nurse must

    see to it that the equipment that monitors
    uterine contractions is recording the moth-
    er’s contractions, the family’s nursing ex-

    pert said.
    Review of the fetal heart monitor trac-

    ings showed several lengthy intervals of
    non-reassuring heart rates. The records

    further revealed that a nurse increased the
    Pitocin even with late decelerations with
    decreased variability, until it was eventual-

    ly decreased and then stopped a few hours
    before birth by a different nurse, but then

    restarted again until the birth with ominous
    tracings showing on the monitor. Abilene
    Reg. Med. Ctr. v. Allen, __ S.W. 3d __, 2012
    5951982 (Tex. App., November 29, 2012).

    The patient’s nursing ex-
    pert explained that the Pi-
    tocin drip is usually con-
    trolled by the labor and de-
    livery nurse.
    It is increased to increase
    contractions and decreased
    or stopped altogether if the
    contractions get too strong,
    too long or too close to-
    The Pitocin is to be adjust-
    ed based on whether the
    baby’s fetal heart tracings
    are reassuring or non-
    reassuring. It is only in-
    creased if the tracings are
    The nursing expert’s re-
    view of the chart revealed
    that the tocotransducer
    which identifies the begin-
    ning and end of each of the
    mother’s contractions was
    not working for the first
    three hours after the mother
    was admitted to the labor
    and delivery unit.
    There were also numerous
    intervals evident from the
    fetal monitor tracings of
    non-reassuring tones that
    should have been but were
    not reported.
    If the physician had been
    notified of the non-
    reassuring tones a cesare-
    an could have been done
    early on to save the child
    from brain damage.

    November 29, 2012

    The Court of Appeals of Mississippi
    ruled there was no deviation from the

    standard of care by the patient’s labor and
    delivery nurses. Norris v. Southwest Miss.
    Reg. Med. Ctr., __ So. 3d __, 2012 6118005
    (Miss. App., December 11, 2012).

    The labor and delivery
    nurse’s assessment was
    correct that the mother was
    not actually in labor.
    When the fetal heart tone
    was lost a nurse promptly
    began trying to reach the
    physician while another
    nurse kept trying to get a
    fetal heartbeat.

    December 11, 2012

    T he patient was admitted to the hospital through the E.R. for what were at the
    time believed to be labor pains.
    She was thirty-one years old and thirty
    -three weeks pregnant and was considered

    high-risk due to obesity, insulin-dependent
    diabetes, four previous cesareans and hav-

    ing given birth to very large twins.
    The labor and delivery nurse immedi-

    ately started a fetal heart monitor and a
    tocodynamometer and performed a vaginal

    exam which showed no dilation of the cer-
    vix. The patient’s ob/gyn who had deliv-
    ered her other children likewise found no

    dilation and gave orders for monitoring her
    blood sugars and giving insulin.

    Later that morning the patient’s ab-
    dominal pain increased and so the nurse

    paged her physician. The nurse was get-
    ting no heart tones on the monitor so she
    asked another nurse to keep checking for a

    fetal heartbeat while she kept paging the
    physician. A few minutes later the physi-

    cian called and said he was on his way.
    The nurse documented all this in the chart.

    The physician was there within
    minutes and delivered the baby by cesare-

    an, but there had been a complete uterine
    rupture and separation of the placenta.

    Labor & Delivery:
    Nurses Ruled Not

    Legal Eagle Eye Newsletter for the Nursing Profession January 2013 Page 3

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    Legal eagle eye newsletter

    For the Nursing Profession
    ISSN 1085-4924

    © 2013/2022 Legal Eagle Eye Newsletter

    Indexed in
    Cumulative Index to Nursing & Allied

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    Sedona AZ 86339-1342
    Phone (206) 718-0861

    The law strongly favors alternative
    methods of dispute resolution such as arbi-

    tration rather than jury trials in civil court
    to resolve claims and disputes, but only if
    both sides have agreed.

    An agreement to arbitrate is basically
    a civil contract. For a contract is to be

    binding both parties must have the capacity
    and the authority to enter into the contract.

    The patient did not have the capacity
    to enter into a binding contract on his own

    behalf because he was quite confused.
    The daughter-in-law had no actual
    authority to sign a contract as her father-in-

    law’s agent. There was nothing to support
    the nursing facility’s argument that the

    patient somehow communicated to the
    facility that he wanted his daughter-in-law

    to sign for him or even had the mental ca-
    pacity to make such a communication.
    A year earlier he had signed a durable

    power of attorney naming his son as his
    attorney in fact. The son was the spouse of

    the daughter-in-law who signed the arbitra-
    tion agreement, but that fact was irrelevant.

    The nursing facility, the Court said,
    made no good faith effort to determine

    who was authorized to sign or to request
    that that person discuss the arbitration
    agreement and make the decision whether

    or not to sign.
    The patient did sign at least one more

    admission contract upon readmission after
    a subsequent hospitalization, when he ap-

    parently was lucid enough to do so, but the
    arbitration agreement was not included.
    Koch v. Keystone Pointe Health & Rehab,
    2012 WL 6098358 (Ohio App., December 10,

    T he patient was transported by ambu-lance from the hospital to a nursing
    facility and was met there by his daughter-
    The daughter-in-law signed the facili-

    ty’s admission contract because the patient
    was quite confused at the time and was not

    lucid enough to sign any papers.
    The daughter-in-law also signed an

    arbitration agreement separate from the
    admission contract. The arbitration agree-

    ment stipulated that all legal claims includ-
    ing negligence, malpractice and violation
    of the resident’s rights, but not non-

    payment of nursing home fees, would not
    be decided in a court of law but would be

    resolved through binding arbitration.
    The patient fell in the nursing home

    and then passed away four months later.
    After his death his daughter as personal
    representative of his probate estate sued

    the nursing facility for negligence.
    The nursing facility petitioned the

    court to dismiss the lawsuit so the case
    could be decided by arbitration as stipulat-

    ed in the arbitration agreement signed by
    the patient’s daughter-in-law.

    The Court of Appeals of Ohio ruled
    the case did not belong in arbitration but
    should stay on the jury trial docket of the

    local county court of common pleas.

    Nursing Home Admission: Daughter-In-Law Had
    No Authority To Sign, Arbitration Agreement Void.

    The patient’s daughter-in-
    law informed the nursing
    facility staff that she did not
    have power of attorney to
    act on the patient’s behalf,
    but the nursing facility dis-
    regarded that fact and told
    her that it would not admit
    the patient if she did not
    sign all the forms, including
    the arbitration agreement.
    Under these circumstanc-
    es there is no evidence the
    nursing facility acted in
    good faith having reason to
    believe that the daughter-in-
    law had authority to enter
    into a legally binding con-
    tract on the patient’s behalf.
    The nursing facility’s de-
    mand that she sign the
    forms lest her father-in-law
    be denied admission for
    necessary rehabilitation did
    not create any apparent au-
    thority for her to bind the
    patient to a contract.

    December 10, 2012

    Legal Eagle Eye Newsletter for the Nursing Profession January 2013 Page 4

    Medication Error: Court Upholds
    Verdict For Nursing Negligence.

    Two physicians testified
    that in their opinion, to a
    reasonable degree of medi-
    cal probability, the nursing
    facility erroneously admin-
    istered anti-diabetic medi-
    cation to the deceased,
    which caused a severe drop
    in her blood sugar.
    Two other physicians, the
    nursing facility’s experts,
    could only speculate that
    malnutrition or a urinary
    tract infection could have
    caused the problem.
    The physicians’ testimony,
    taken along with the testi-
    mony of two former nursing
    home employees as to the
    chaotic conditions at the
    facility, supports the jury’s
    verdict against the facility.
    The nursing facility had
    complete control of the anti
    -diabetic medication at the
    facility that was being taken
    by residents who used such
    medication, that is, none of
    the four residents who ad-
    ministered their own medi-
    cations were on such medi-
    It is not a realistic explana-
    tion that anti-diabetic medi-
    cation was given to this res-
    ident by a third party. Even
    if that did happen it would
    amount to lax supervision
    of the residents’ environ-
    ment which itself would be


    December 19, 2012

    T he eighty year-old nursing home resi-dent suffered from Parkinson’s dis-
    ease, dementia and the aftereffects of a
    stroke at age seventy-four.
    She had no history whatsoever of dia-

    betes or hypoglycemia.
    She was found unresponsive in her

    room in the middle of the morning and was
    rushed to the hospital where her blood glu-

    cose was discovered to be 12.
    The patient was diagnosed with en-

    cephalopathy due to hypoglycemia which
    the physicians suspected came from oral
    ingestion of anti-diabetic medication.

    The patient came out of her coma but
    never regained her semi-independent func-

    tioning and died within fifteen months.
    The jury awarded the family $1,250,000 as

    punitive damages, $400,000 for her pain
    and suffering and $554,000 attorney fees
    and costs. The US Court of Appeals for the

    Sixth Circuit (Ohio) upheld the verdict.
    Disturbing Conditions At The

    Nursing Home

    Two former employees of the nursing

    home described disturbing conditions at
    the facility, including disorganized medica-

    tion carts, pre-pouring of medications and
    falsification of medical records.

    There were only two LPNs assigned
    for the care of eighty residents. The LPNs
    were often rushed and as a result of their

    haste regularly engaged in the practice of
    pre-pouring medications. The medication

    cart was “a mess” most of the time. The
    wrong pills were in the medication trays.

    The nurses would borrow medication from
    one resident and give it to another. At the
    time of her death more than fifty of this

    resident’s pills were found to be missing.
    A supervisor altered records to cover

    up a medication error. Staff and supervi-
    sors routinely filled in “holes” in residents’

    medication administration records retroac-
    tively at the end of the month.
    In the Court’s judgment, the whole

    situation went beyond simple negligence
    and justified the jury’s decision to award

    punitive damages for conscious and mali-
    cious disregard of the resident’s well estab-

    lished legal right to a safe environment free
    from significant medication errors. Freude-
    man v. Landing, __ F. 3d __, 2012 WL 6600356
    (6th Cir., December 19, 2012).

    W hen the inmate was booked into the jail his medical history included the
    fact he was being treated by a local spe-
    cialist for autoimmune chronic hepatitis,
    esophageal varices, anemia, jaundice and

    Early in the a.m. the day after being

    booked he vomited a large puddle of blood
    in his cell. He explained to a jail officer

    that he had gastric ulcers for which he took
    numerous medications and that he had had

    twenty-seven units of blood transfusions
    during the previous month.
    The officer phoned one of the jail

    nurses at home and explained the situation.
    She told the officer to give him some liq-

    uid antacid. He threw up lots more blood
    again. When she was phoned again the

    nurse told the officer to give him a Phener-
    gan suppository. When they phoned her
    again the nurse finally decided to come in

    to the jail. She had the inmate moved to
    medical solitary and continued the supposi-

    tories. The next day the inmate died from
    a massive gastrointestinal hemorrhage.

    Nursing: Court
    Says Nurse Was

    The nurse violated the in-
    mate’s Constitutional rights
    through deliberate indiffer-
    ence to his serious medical


    December 12, 2012

    The US Court of Appeals for the Fifth
    Circuit (Texas) placed blame on the nurse
    for failing at least to alert the physician and
    for not sending the inmate to the hospital
    due to the seriousness of his condition.
    Deputies working for the county sher-
    iff who was responsible for the jail did all
    they were expected to do and the jail phy-
    sician was never informed by the nurse
    what was actually going on with this in-
    mate. Bolin v. Wichita County, 2012 WL
    6194359 (5th Cir., December 12, 2012).

    Legal Eagle Eye Newsletter for the Nursing Profession January 2013 Page 5

    Age Bias: Court
    Sees Grounds For
    CNA’s Lawsuit.

    A n Hispanic CNA in her mid-fifties had consistently positive performance
    reviews and was rewarded with pay raises
    for more than sixteen years and was recog-
    nized for her service by being selected for

    the Resident Care Specialist Leadership
    Council at the nursing home.

    Then a new director of nursing took
    over. A few months later the CNA was

    suspended and then fired over an incident
    involving alleged substandard care of a

    total-care patient.
    The CNA sued for race and age dis-

    The US District Court for the District
    of Colorado found evidence to support the

    allegations of age discrimination.
    As soon as she came on board as inter-
    im DON the person who would eventually

    become the new permanent DON started
    making remarks to the CNA pointing out

    that she was the oldest CNA in the facility
    and was “as old as the woodworks,” asking

    her when she was going to retire, telling
    her that she was too old for her job and

    telling her that she was “like an old penny
    that keeps coming back.”
    As interim DON she also reportedly

    threatened the CNA that she was going to
    be watching her closely and would fire her

    as soon as she became permanent DON.
    The CNA was told this well before the

    occurrence of the patient-care incident that
    was used ostensibly to justify her firing.
    Alfonso v. SCC Pueblo, 2012 WL 6568468 (D.
    Colo., December 17, 2012).

    A discriminatory motive
    can be seen in the DON’s
    derogatory remarks about
    the CNA’s age.
    These remarks raise seri-
    ous questions whether the
    patient-care incident was
    merely a pretext to move
    the CNA out because of her


    December 17, 2012

    Race Discrimination: Nurses Did
    Not Prove Their Case.

    A fter complaining about various as-pects of their working conditions over
    a span of several years, two minority nurs-
    es sued their employer for race discrimina-

    The lawsuit alleged they were victims
    of discrimination as well as victims of re-

    taliation for their complaints about what
    they considered to be discrimination.

    The US Court of Appeals for the Sev-
    enth Circuit (Illinois) dismissed their case.

    More Favorable Treatment Alleged

    For Non-Minority Nurses

    The two African-American nurses,
    before filing their lawsuit, had delivered a
    written petition to human resources at the

    hospital complaining that Filipino nurses
    were being given easier assignments, more

    training and more leadership opportunities.
    These allegations were apparently

    investigated by human resources and dis-
    missed as unfounded.
    The Court said that these allegations,

    if they could be proven, would certainly be
    adequate grounds for a civil rights lawsuit.

    However, a lawsuit cannot be based simply
    on vague assertions and innuendo.

    For a successful discrimination lawsuit
    the alleged victim must identify a specific

    person or persons who were treated more
    favorably, specify the manner in which
    they were treated more favorably and show

    that they were similar to the victim in all
    relevant respects except for not being a

    racial minority. There was no specific
    person or persons identified for purposes

    of comparison in the nurses’ lawsuit.
    Alleged Harassment

    Was Not Racially Motivated

    The two nurses were criticized and
    given negative performance evaluations for

    lack of teamwork. One of them was called
    a “trouble maker,” a “cry baby” and a

    “spoiled child” in one particular meeting
    with a supervisor and had to leave the

    meeting in tears.
    Even if all this was true, the Court was
    not able to find any discriminatory racial

    motivation behind the nurses’ supervisors’
    actions, which is a necessary element for

    them to be able to go forward with a civil
    rights lawsuit against their employer.
    Brown v. Advocate, __ F. 3d __, 2012 WL
    5870725 (7th Cir., November 21, 2012).

    The alleged victims con-
    tend that the Court can infer
    racial bias from the fact that
    their employer did not re-
    spond to their complaints
    as they would have liked.
    The fact that someone dis-
    agrees with you or declines
    to take your advice, without
    anything more, does not
    suggest that they are dis-
    criminating against you.
    All of the supervisors’ crit-
    icisms used non-racial lan-
    guage and there was noth-
    ing in the context to sug-
    gest the criticisms were ra-
    cially motivated.
    Perhaps their supervisors’
    criticisms were unfair, but
    there is no evidence that
    the criticisms were motivat-
    ed by race.
    The civil rights laws pro-
    tect against discrimination,
    not personal animosity or
    juvenile behavior.
    Over a two-year period the
    alleged victims made nu-
    merous complaints to man-
    agement, some involving
    racial issues and others in-
    volving general workplace
    The complaints were in-
    vestigated. Action was tak-
    en on some of them and de-
    clined as to others. The al-
    leged “harassment” was
    only negative feedback
    about lack of teamwork.

    November 21, 2012

    Legal Eagle Eye Newsletter for the Nursing Profession January 2013 Page 6

    Flu Immunization:
    Public Health
    Emergency, Nurse
    Cannot Be Sued.

    I n 2009 in response to an outbreak of H1N1 influenza the US Secretary of
    Health and Human Services made a formal
    declaration that a public health emergency
    existed and recommended administration

    of a specific antiviral vaccination.
    The Secretary’s authority came from

    the US Public Readiness and Emergency
    Preparedness (PREP) Act of 2005.

    The Governor of New York then is-
    sued an executive order authorizing state

    and local authorities to take steps to dis-
    tribute and administer the vaccine.
    A local county health department held

    a vaccination clinic in a local school where
    a nurse gave a kindergartener the flu vac-

    cine without either parent’s consent.
    The child’s mother sued the county

    health department for negligence and civil
    battery. The New York Supreme Court,
    Appellate Division, dismissed the case.

    Continued on page 7.

    The US Public Readiness
    and Emergency Prepared-
    ness Act protects licensed
    health professionals who
    are authorized to administer
    or dispense countermeas-
    ures in response to a public
    health or bioterrorism emer-
    The Act does not detract
    from a licensed healthcare
    professional’s legal immun-
    ity when a countermeasure
    is administered without
    As a Federal law the Act
    takes precedence over any
    state statute or rule of the
    common law that goes con-


    November 21, 2012

    Skilled Nursing: Court Finds
    Substandard Procedures,
    Upholds Civil Monetary Penalty.

    A fter the death of a seventy-eight year-old patient who had been on Couma-
    din for a blood clot in her leg, survey in-
    spectors decided that the facility’s proce-
    dures for laboratory work were out of com-

    pliance with Federal standards.
    A civil monetary penalty was levied of

    $3050 per day for more than half a year,
    the period of time during which the facili-

    ty’s procedures were deemed out of com-
    pliance, more than $587,000, which was

    upheld by the US Court of Appeals for the
    Fourth Circuit (North Carolina).

    Resident’s Death Sparks Investigation

    A nurse saw and charted swelling in

    the patient’s lower leg and reported it to
    the patient’s physician. He ordered a Dop-

    pler test which found a blood clot. The
    physician ordered 10 mg of Coumadin plus

    Lovenox daily and daily PT/INR tests.
    The care plan was “badly mishandled”
    according to the Court and the PT/INR

    testing did not begin for over a month.
    The first result showed a critically high

    Coumadin level.
    After the same result two days later

    the physician scaled back the Coumadin to
    6 mg. The order for a follow up PT/INR

    was not properly transcribed and the PT/
    INR was delayed two more days until an-
    other nurse caught the mistake.

    The blood sample was sent back by
    the lab as too small to test so a nurse tried

    to draw another the next day. The patient
    refused the blood draw, which was her

    right, but any such refusal has to be report-
    ed promptly to the physician, which was
    not done.

    The nurse did see and charted unusual
    bruising around the breast and shoulder,

    possible signs of a Coumadin overdose, but
    that also was not reported to the physician

    as it should have been.
    Finally a sample was drawn which
    showed a critically high Coumadin level

    and the patient was sent to the hospital.
    The hospital administered one dose of Vit-

    amin K, but the family then decided to
    decline further treatment and the patient

    passed away the next day. Universal
    Healthcare v. Sebelius, 2012 WL 6217619 (4th
    Cir., December 14, 2012).

    A skilled nursing facility is
    required by Federal regula-
    tions to ensure that each
    resident’s drug regimen is
    free from drugs given in ex-
    cessive doses, for exces-
    sive duration or without ad-
    equate monitoring in the
    presence of adverse conse-
    quences which indicate the
    dose should be reduced or
    A skilled nursing facility
    must have a system in
    place to ensure that labs
    are drawn when ordered,
    drawn correctly, processed
    correctly and the results re-
    ported to the patients’ phy-
    Residents on anticoagu-
    lant therapy require not on-
    ly lab tests but also proto-
    cols for monitoring and ob-
    servation by direct caregiv-
    Special instructions for
    Coumadin should be placed
    in care plans that any sub-
    tle signs of injury should be
    At this facility there was a
    systematic failure to antici-
    pate and plan for the risk of
    bleeding, to monitor for ad-
    verse reactions and to in-
    struct rank-and-file staff on
    touching and handling resi-
    dents on Coumadin.

    December 14, 2012

    Legal Eagle Eye Newsletter for the Nursing Profession January 2013 Page 7

    Nursing Assessment: Damages
    Awarded For Negligence.

    There was no error by the
    judge who assigned fault
    100% to the night nurse and
    held the agency that sup-
    plied her to the hospital
    100% liable for the $1.4 mil-
    lion judgment.
    The day nurse, the hospi-
    tal and the treating physi-
    cian were properly dis-
    missed from the lawsuit.
    There was no evidence the
    day nurse breached the
    standard of care in her
    nursing assessments or her
    nursing care of the patient.
    There was nothing wrong
    with the treating physi-
    cian’s initial diagnosis and
    plan of care for the patient.
    The patient was already
    irreversibly paralyzed by
    the time the hospital’s resi-
    dent was alerted to the pa-
    tient’s condition by the
    night charge nurse. The
    medical review panel criti-
    cized him for delay in ob-
    taining the diagnostic
    scans, but even if the scans
    were done and the neuro-
    surgeon came in and oper-
    ated earlier the outcome
    would not have changed.
    When the treating physi-
    cian was finally contacted
    during the night by the resi-
    dent at the hospital, there
    was likewise nothing he
    could have done at that
    point that would have
    changed the outcome.

    December 5, 2012

    Continued from page 6.

    Legal Immunity

    Healthcare Professionals

    Countermeasures in a Declared

    Public Health Emergency

    The PREP Act states that a covered
    person shall be immune from suit and lia-

    bility under Federal and state law with
    respect to all claims for loss caused by,

    arising out of, relating to or resulting from
    the administration of a covered counter-
    measure to an individual.

    The definition of a covered person
    includes licensed health professionals or

    other individuals who are licensed by the
    state in which the countermeasure was

    prescribed and authorized to administer
    and dispense such countermeasures.
    The only exception to the broad sweep

    of immunity granted to covered persons
    with respect to administration of counter-

    measures is for death or serious injury
    caused by willful misconduct.

    Congress also enacted the Counter-
    measures Injury Compensation Program

    creating an administrative agency to handle
    claims for certain injuries stemming from
    countermeasures taken in response to the

    declaration of a public-health emergency,
    which was intended to be the exclusive

    legal remedy for persons with such claims.
    Lack of Consent Does Not Create

    Basis for Legal Action

    The Court was not persuaded that an

    exception should be read into the PREP
    Act, as argued by the mother in her law-
    suit, for situations involving a duly de-

    clared public health emergency where a
    countermeasure is administered without

    informed consent. A healthcare provider
    could be held liable if an immunization

    was given without consent under normal,
    everyday circumstances.
    The Act itself and supporting Federal

    regulations and an Executive Order from
    the President make no mention of any in-

    tent by Federal lawmakers for the courts to
    read in such an exception. Parker v. St.
    Lawrence County Public Health Department,
    __ N.Y.S.2d __, 2012 WL 5869773 (N.Y. App.,
    November 21, 2012).

    T he patient was an insulin-dependent diabetic with a history of drug abuse.
    During the night he was admitted to
    the hospital suffering from abdominal pain,
    back pain and vomiting which had caused

    severe dehydration.
    The diagnosis was diabetic ketoacido-

    sis which his physician intended to treat by
    gradually restoring hydration and correct-

    ing his blood sugars through careful insulin

    At 9:00 a.m. the physician determined
    that his condition was improving and or-
    dered his IV hydration, antibiotics and

    blood sugar testing continued.
    The day nurse performed two head-to-

    toe assessments of the patient. She charted
    that the abdomen was soft, that there were

    active bowel sounds and that the patient
    was voiding yellow urine. He had equal
    range of motion in his upper and lower

    extremities, equal and strong extremity
    strength and a steady gait.

    Night Nurse’s Assessments

    Significant Findings Not Reported

    At 7:00 p.m. the night nurse who was
    an agency nurse took over the patient’s

    care. Right away the patient’s wife in-
    formed the nurse that his legs were numb

    and that one leg had flopped out of the bed.
    The nurse told the wife this was caused by
    his fever. The nurse did not report this to

    the charge nurse or to a physician.
    At 8:15 p.m. the night nurse did her

    first head-to-toe assessment. She charted
    that the abdomen was firm and strength

    was weak in all the extremities. There was
    no charting as to weakness being equal or
    unequal and her note for sensation was

    “unable to assess.” There was no report to
    the charge nurse or to a physician.

    At 3:40 a.m. the patient told the nurse
    he could not move his legs at all. He had

    not voided since 1:30 p.m. the previous
    afternoon, so the nurse inserted a Foley
    and obtained a large amount of dark urine.

    Finally the nurse notified the charge
    nurse who called in a resident. By this

    time the patient was irreversibly paraplegic
    from an epidural abscess in the thoracic

    spine which could not be corrected surgi-
    cally. The Court of Appeal of Louisiana

    approved a $1.4 million judgment. John-
    son v. Ray, __ So. 3d __, 2012 WL 6055584
    (La. App., December 5, 2012).

    Flu Immunization:
    Public Health
    Emergency, Nurse
    Cannot Be Sued.

    Threat Of Violence: Nurse’s Termination Upheld,
    Allegations Of Sexual Harassment Dismissed.

    A nurse was fired after she made a remark to one coworker that was
    interpreted as a threat to shoot another
    coworker over a remark he made to her

    about her husband leaving her.
    After being fired she sued the hos-

    pital for sexual harassment and for re-
    taliation for reporting sexual harass-
    ment. The sexual harassment, she said,

    involved the coworker whom she later
    threatened being a little too friendly,

    smiling and staring at her too much and
    making one vulgar sexually-oriented

    remark to her.
    The US Court of Appeals for the

    Tenth Circuit (Oklahoma) dismissed the
    nurse’s case.
    A lawsuit for a sexually hostile

    work environment can only be based on
    conduct that permeates the workplace

    with intimidation, ridicule and insult.

    Garden-variety boorish, immature,
    juvenile and annoying behavior is not

    uncommon in the American workplace
    and does not give grounds for a lawsuit

    for sexual harassment, the Court said.
    Another important factor was that

    the nurse was the perpetrator’s supervi-
    sor, not the other way around.
    The most important factor in the

    Court’s mind was that the hospital had
    legitimate, non-discriminatory and non-

    retaliatory grounds to terminate the
    nurse, her threat of violence against a

    She reportedly told a coworker she

    owned a .357 magnum handgun and
    knew how to use it and stated that the
    kind of remark another coworker

    voiced to her about her marriage was
    the kind of thing that gets people shot.
    Gaff v. St. Mary’s Reg. Med. Ctr., 2012 WL
    6604579 (10th Cir., December 19, 2012).

    The reason given by the
    hospital for the nurse’s ter-
    mination, that she made a
    threat of violence against a
    fellow employee, was not a
    pretext to cover up a plot to
    fire her for her complaint
    about sexual harassment.
    The nurse told a coworker
    that she owned a gun and
    knew how to use it and said
    that what her coworker said
    to her was the kind of thing
    that gets people shot.


    December 19, 2012

    Stolen Prescription Form: Nurse Practitioner
    Implicated In Narcotic-Overdose Death.

    A physician and a nurse practitioner em-ployed in a Federally-funded community
    health clinic were originally named as defend-
    ants in a wrongful-death lawsuit arising out of

    the death of the nurse practitioner’s daughter’s
    friend from acute fentanyl poisoning.

    The deceased was found dead with a partial-
    ly dissolved 1600 mcg Actiq lozenge in her
    mouth. Post-mortem toxicology also found

    Xanax in her system.
    The Actiq lozenge was apparently the last of

    six obtained by the deceased from a community
    pharmacy using a prescription form signed in

    blank by the physician and given to the nurse
    practitioner and then stolen by the deceased or

    given to the deceased by the nurse practitioner’s
    The daughter was charged with criminal

    offenses in connection with the death but died
    herself before her case went to court.

    The investigation revealed that the deceased
    had previously come into possession of three

    other blank prescription forms from the same
    clinic signed by the same doctor and had used
    them to get drugs before she met her end.

    The US District Court for the Middle Dis-
    trict of Georgia ruled the physician and the nurse

    practitioner were negligent because their conduct
    in signing and handling blank prescription forms

    violated the clear letter of state law.
    Civil liability was appropriate because it is

    foreseeable that illegally pre-signed prescription
    forms can be stolen, passed on, forged and used
    to obtain controlled substances to be used in an

    illicit manner which can cause a person’s death.
    However, the physician and nurse practi-

    tioner were employees of a Federally funded
    community health clinic. Under Federal law the

    US Government has had to step in as the defend-
    ant and try to defend their actions as they cannot

    be sued individually even if they were negligent
    and their negligence caused harm, a legal techni-
    cality not available to caregivers in the private

    sector or in many state-run healthcare settings.
    The Government’s argument will be that the

    nurse practitioner’s daughter’s criminal act sup-
    plying the form to her friend was an intervening

    cause that relieves the Government from liabil-
    ity, but the Court has not yet ruled on that issue.
    Eaton v. US, 2012 WL 6203002 (M.D. Ga., December
    12, 2012).

    Legal Eagle Eye Newsletter for the Nursing Profession January 2013 Page 8


















    Read the two case summaries provided 


    . The case summaries are on page 2. Once you read the two case summaries, follow the instructions below.

    Compare the appropriate nursing interventions by the nurse completed in Mississippi to the inappropriate nursing interventions by the nurse in the Texas case. Provide rationale supporting your comparison citing at least two scholarly sources.

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