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Please identify and all legal and ethical issues and provide a plan of action to deal with each issue
Here is the scenario:
You are the risk manager for your facility. Your duties include managing all of the hospital’s medical malpractice litigation, working with the insurance claims representative and the defense attorneys. You interface with other departments in your facility when you have issues involving their staff. You regularly work with the HR staff when issues you uncover in your cases involve current staff. Finally, you meet with the Compliance Officer on a regular basis to discuss any issues that may impact the organization’s compliance with state and federal regulations.
Your facility is working diligently to improve its standing in the region. You and your fellow administrators are expanding the services that you provide. You have been providing neurosurgical services for quite some time and have good reputation in the area for your neurosurgical team’s performance. In order to retain the best neurosurgeons in the area, you are also enhancing the services provided in your intensive care unit (ICU). At their request, more equipment has been purchased and additional services have been provided since 2005. The additional revenue from those services has funded improvements throughout the hospital. Yet, not all improvements are progressing at the same pace.
One issue that is nagging all departments is your conversion to electronic medical records. You are behind the curve in some areas and still relied on paper charting until just a couple of years ago. Some of those areas include various patient care units, including the ICU.
In June 2007, Sam Lawson was admitted to your hospital. He was an active 67 year old husband, father and grandfather. Despite his age, he still worked regularly as a consultant for the engineering firm he started years before. He enjoyed a fairly good income from his work. In April 2007, he began having headaches. Following an MRI, it was determined that he had a brain tumor. The morphology and other tests revealed that it was most likely benign. He was to undergo surgery for the removal of the benign brain tumor. His prognosis for full recovery was very good.
Dr. Belmont was his neurosurgeon. He had a pristine medical malpractice history and has been a credentialed provider on your medical staff for many years. Dr. Belmont is a cautious provider. Dr. Belmont was concerned about the possibility of Mr. Lawson’s brain swelling following surgery. Therefore, Dr. Belmont placed an intracranial pressure (ICP) monitoring line into the ventricles of his brain. This line allowed the nursing staff to monitor the pressure in Mr. Lawson’s brain. They were to alert Dr. Belmont if there were any increases in the ICP beyond acceptable parameters set in the postoperative orders written by Dr. Belmont. Mr. Lawson also had orders for IV morphine for pain or agitation. Dr. Belmont wanted him to be calm postoperatively. He also requested that Mr. Lawson be placed in one of the more isolated and quiet rooms to reduce stimulation. Dr. Belmont wasn’t concerned about Mr. Lawson’s location because he knew that he would have his own nurse while in ICU who would be monitoring his vital signs frequently.
After Mr. Lawson’s surgery, he was sent to ICU. He had orders for monitoring of his vital signs and ICP every 15 minutes for the first hour then every half hour thereafter. In this facility, this intensive monitoring is the standard and followed policies for ICP monitoring. Mr. Lawson’s initial postoperative hours were uneventful. He was cared for by a very conscientious nurse, Nurse Albert. At shift change from day shift to evening shift, Nurse Albert noted that she was to be followed by Nurse Cusack. Nurse Cusack would not have been Nurse Albert’s initial choice; but, she knew that the ICU was short-staffed and there were numerous temporary staffing agency nurses working that evening. At least Nurse Cusack was one of the regular staff. Nurse Albert knew that Nurse Cusack had a history of being written up for tardiness, excessive break times and attitude issues. She also did not consider her the most attentive nurse in the ICU. Nurse Albert reported Mr. Lawson’s condition to Nurse Cusack. She noted that Nurse Cusack appeared tired which Nurse Cusack brushed off as a busy day before reporting for her evening shift. When pressed for more assurance by Nurse Albert that she was OK, Nurse Cusack became agitated and said that she was fine. Nurse Albert was concerned. Yet, this behavior was the norm that everyone had come to accept for Nurse Cusack and she chalked up her behavior to Nurse Cusack’s explanation that she had had a busy day.
Nurse Cusack assumed Mr. Lawson’s care. She did his initial vital signs and ICP reading and seemed to be attentive for the first few hours of the shift. Nurse Minor, the charge nurse, was making rounds that evening. When checking Mr. Lawson’s charting, she noted that a set of vital signs and ICP reading had not been recorded for over 40 minutes. Nurse Cusack was not in the room. She started looking for Nurse Cusack and found her as she was exiting the bathroom. She seemed a bit confused by Nurse Minor’s concerns and went back to Mr. Lawson’s room. The ICU got very busy and Nurse Minor spent most of the rest of the evening dealing with issues related to the agency nurses and their need for extra attention.
Near the end of the shift, the ICU staff responded to a call for help coming from Mr. Lawson’s room. As the staff entered, they found Nurse Cusack hovering near the head of the bed and assessing Mr. Lawson’s pupils. He was unresponsive and one of his pupils was larger than the other. This is an indication of pressure building up in his brain. The ICP monitor had not alarmed. Nurse Cusack exclaimed that the alarm must not be working. When his ICP was checked, it was found to be far above the acceptable range established by Dr. Belmont in the postoperative orders. Dr. Belmont was called and he assessed Mr. Lawson. Dr. Belmont determined that Mr. Lawson’s ICP had risen to dangerous levels. He writes in the chart that Mr. Lawson would most likely suffer permanent brain damage. He looked at the charting of the vital signs and ICP. All of the vital signs and ICP readings that were recorded appeared to be normal. He could not explain the sudden rise in Mr. Lawson’s ICP. Appropriate treatments for an elevated ICP were initiated and the remainder of Mr. Lawson’s stay was without incident.
It is now almost five years after the events of that June. Mr. Lawson regained minimal brain function and is bedridden. His family provides care for him at home with the assistance of home aides. His family sued Dr. Belmont and your hospital. The discovery phase has been progressing slowly. The attorney representing Mr. Lawson and the family is Mr. Lawson’s nephew. He has been an attorney for little over a year. This is his first big case. In initial discussions with your defense attorneys, he has alluded to the fact that this is a multimillion dollar case. He has requested the deposition of Nurse Cusack.
Your defense attorney and insurance claims representative are preparing Nurse Cusack for her deposition. During her preparation, she breaks down and starts crying. That’s when the real story comes out. She has been a morphine addict for years. She states that Nurse Minor is aware of her problem and has been helping her cope with her addiction. Nurse Minor used to work in a drug rehabilitation unit. The evening of Mr. Lawson’s surgery, Nurse Cusack was personally using Mr. Lawson’s morphine. She had inserted a heparin lock (sometimes called a saline lock) into her leg and hid it with her scrubs. She would sign out Mr. Lawson’s morphine then go to the bathroom and inject it in her heparin lock. Nurse Cusack believes that Nurse Minor watched her patients more closely than those of the other nurses. She thinks that is why Nurse Minor found the missed set of vital signs and ICP reading and went looking for her. Once she realized that she was being watched that evening, she fabricated a set of vitals and an ICP reading for the set that had been missed. Because she was actively using morphine that evening, she was not monitoring or recording the vital signs and ICP as ordered. When she noted late that evening that Mr. Lawson was unresponsive, she fabricated the vital signs and ICP readings making it look as if she had been performing the required checks and that all of them had been normal. After she finished her story, she asked what would happen to her now. The insurance claims representative and your defense attorney said that they would discuss what they had learned with the hospital Risk Manager.They share the story with you. After your initial shock, you remember that your insurance policy does not cover intentional acts by your employees. You also remember that Dr. Belmont is named in the suit. Any settlements would necessarily involve him too. He has his own defense team defending his actions. They also share that Nurse Cusack’s deposition is set for three weeks from the day that you hear this story. There are no current offers to settle the case and no mediations to negotiate a settlement are scheduled.
You contact HR in order to determine what is in Nurse Cusack’s employment file. There is no reference to any disciplinary actions. It is immediately apparent that Nurse Cusack has never been caught using morphine at work. Her performance evaluations are average to poor with occasional reference to not returning from her breaks in a timely manner. She has never been on corrective action. Her license is in good standing. As well, Nurse Minor is still your employee. You request her employment file too. Her file is unremarkable. Her deposition has not been requested.
Mr. Lawson is a Medicare patient. In your last meeting with the Compliance Officer, you learned that the hospital is the target of an investigation by the U.S. Attorney’s office. There are allegations in a qui tam action that you overcharged Medicare for services provided in your ICU. The complaint alleges that the hospital led the Medicare program to believe that its Intensive Care Unit had the capability to perform certain critical care services. The U.S. Attorney is reviewing charts and billing to determine if the unit possessed such capability. The time frame being investigated is March 2006 to January 2008.
The insurance claims representative and your defense attorney have left your office. You are alone to gather your thoughts. You have to determine how you will proceed with all of the information you now know.
What do you do?
Description of the Assignment
1. Your submission should be no more than two thousand five hundred (2500) words.
2. Identify each issue in this case study whether it be a legal issue or an ethical issue. Describe why it is an issue. Present your suggested plan of action to deal with the issue.
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