Legal Implications

Before you enter this discussion, please complete your unit reading assignment. Please read the Case 5 “Wound Care at Mountainview Nursing Center” on pages 535-537 in

your text. Then respond to the following questions from your text in your original post:

Evaluate the legal implications of the nursing care that Mr. Harris received while a patient at Mountainview Nursing Center.
Would a physical restraint be appropriate to prevent falls in this situation?
Discuss the care of Mr. Harris from the standpoint of his rights as a patient.
In this situation, how would you ensure that the patient’s own wishes are carried out?
Why do you think that the nursing home corporation settled this case out of court? Would you have let the litigation proceed through the court system? Why? Do you

think the facility would be held liable? Why?
It was assumed that the patient’s agitation caused the dressing to dislocate. Could the facility have done anything to prevent that?
What actions would you take to assess and improve infection control practices in the nursing following Mr. Harris’s discharge?

Case study

Wound Care at Mountainview Nursing Center THE ASSISTANCE OF PATRICK CLAUDIUS, MD, IN DEVELOPING THIS CASE IS GRATEFULLY ACKNOWLEDGED. Subsequent to his discharge

from a local acute care hospital where he had received treatment for pneumonia, Jim Harris was admitted to Mountainview Nursing Center five years ago. Mr. Harris was

83 years old. According to the minimum data set (MDS) assessment, the patient had various chronic comorbid conditions. These conditions persisted over a period of two

years while Mr. Harris was a patient at Mountainview. The patient was eventually discharged to an acute care hospital and never returned to Mountainview. Mountainview

is a 112-bed dually certified nursing care facility affiliated with a for-profit multifacility chain. The nursing home is located in a rural county with a population

of 27,000. The median household income in the county is $32,900. Approximately 64% of the adults over the age of 25 have completed a high school education; 10% of the

adult population have finished a bachelor���s degree or higher. Mr. Harris���s daughter, Nancy, had the power of attorney for the patient���s medical treatment. Nancy

visited the facility regularly and did not express any notable concerns with her father���s care at Mountainview.

Medical and Nursing Evaluations and Treatments Diagnoses at the Time of Admission ��� Diabetic gangrene of the foot (heightens the risk for septicemia).

��� Peripheral vascular disease (causes poor healing of wounds). ��� Congestive heart failure (poses high surgical risk).

��� Depression.

��� Short-term memory loss.

��� Dysphagia (increases the risk of nutritional deficiency).

��� Unsteady gait; a walker was used for ambulation.

Main Observations

The patient had a vascular (ischemic) ulcer.* Necrosis of the tissues had set in, the wound was infected, and purulent discharge was observed.

Treatments

The wound���s dressing was to be changed once a day, and Accuzyme, a topical medicine, was to be applied with each dressing change. Protein supplements, zinc supplement,

and multivitamins were ordered to promote healing of the wound. The patient needed insulin for diabetes. In addition to daily dressing change, the wound was measured

once a week. The patient was also referred to a specialized wound care center located 45 minutes away from Mountainview. The patient received wound care once a month

at the wound care center. At Mountainview, Mr. Harris also received intermittent physical therapy to promote circulation and speech therapy for dysphagia. While the

patient was in the hospital, before his admission to Mountainview, a Doppler study was conducted to evaluate arterial circulation in the leg. The test showed a severe

blockage in the leg. Consultation with a vascular surgeon was recommended. However, Nancy refused the consultation on grounds that surgery presented too great a risk

given the patient���s medical condition. Nancy also refused the insertion of a G-tube through which the patient could ingest specialized nutritional formulas. A general

surgeon had recommended amputation of the leg because of the gangrene. Nancy considered this to be too drastic a measure and did not opt for it. The surgeon as well as

the patient���s attending physician had discussed with Nancy the risks and benefits of leg amputation versus nonsurgical treatments. According to medical opinion,

amputation presented the least risk. However, Nancy had anticipated that over time her father���s wound would heal. As time progressed, Nancy showed growing frustration

that the wound was not healing. Although some progress would be noted at times, it would be followed by deterioration. The ups and downs in the healing process

persisted.

Incidents and Outcomes

In the final 30 days of the patient���s stay at Mountainview, the patient sustained a fall from wheelchair to floor. Mr. Harris did not have a history of falls even

though his gait was unsteady. A restraint was not recommended and was not used. When the patient was in a wheelchair, the nursing staff used a personal alarm that

would alert the staff to any forward movement or leaning from the wheelchair. However, by the time the staff came to see what had happened, the fall had already

occurred. The nurses did not notice any injuries from the fall, but the patient was sent to the hospital for evaluation. Within two weeks of the fall, the patient

developed pneumonia and was hospitalized, but he returned to Mountainview within three to four days. One morning a nurse found that the dressing had slipped from the

wound. At times the patient was agitated. Hence, the nurse believed that the patient may have kicked off his dressing while he was agitated. On closer examination, the

nurse saw maggots in the wound. The wound was cleaned with saline solution, and the dressing was changed. In the afternoon, maggots were found again. In accordance

with nursing protocols, Nancy was informed, and the medical director, who was also the attending physician for this patient, was notified. The patient was transferred

to the hospital���s emergency room. The patient never returned to Mountain-view. Three months later, the facility was informed that it was named as the defendant in a

lawsuit. Mountainview���s corporate office settled the lawsuit out of court for an undisclosed amount.