Nurse documentation contributes to lawsuit dismissal

The 2018 lawsuit Schaetzel vs Mercy Health Services-Iowa illustrates how documentation and professional conduct can be key factors in litigation.

In the case, William was the temporary guardian for his father-in-law, Harold, who was admitted to the hospital for treatment, presumably because of malnourishment. Harold was placed on tube feedings.

During a visit with his father-in-law, William decided to use a ballpoint pen to puncture the hanging plastic nutrition bag so the infusion would flow faster. The nurse caring for Harold contacted the nursing supervisor when she determined what had happened.

The nursing supervisor immediately spoke with William and documented in Harold’s medical record what was discussed.

The documentation included the following:

  1. When the nursing supervisor approached William, two women were “scratching his head as if [he] were a dog and he was kicking his legs and giggling.”
  2. The nursing supervisor introduced himself and asked if William was “interrupting the administration of the tube feeding.”
  3. William responded with a smile and said he “was a physician” with a “type-A personality,” that he “thought it wasn’t going fast enough,” that he thought “there was a vacuum within the bottle so he punctured it and then all of the fluid started to … come out.”

The nursing supervisor told William his action was unacceptable and he acknowledged it was and said he would not do it again. He was instructed to call the nursing staff if he had questions about the feeding tube in the future and he said he would do so.

William then asked if the rate of the feeding tube could be increased because of Harold’s malnutrition. The nursing supervisor explained that the risk of aspiration, pneumonia, suffocation and drowning with the feeding tube was why the rate was regulated.

William responded, “Yes, yes, yes, I understand all of that; after all, I am a physician.”

Two days later, William contacted the hospital pharmacy and spoke with one of the pharmacists about the “accuracy of the pumped feedings being administered” to Harold. The pharmacist was to contact the dietary department but did not do so.

Several days later, a hearing was held to determine if Harold continued to need a guardian. The Iowa District Court determined that Harold did not want a guardian; the temporary guardianship was terminated and William was removed from that position.

Lawsuit begins

William then filed a suit against the hospital in the United States District Court for the Northern District of Iowa alleging defamation of character, breach of contract, injurious interference with contract and invasion of privacy.

After several legal filings, only three allegations remained:

  1. The nursing supervisor falsely documented his conversations and actions in the medical record, which “defamed [him] and cast him in a false light.”
  2. The pharmacist breached an oral contract to contact the dietary department about his concerns.
  3. He suffered from injurious interference with contract.

The hospital filed a Motion for Summary Judgment stating there was no material issue of fact or facts in the lawsuit and, therefore, the hospital was entitled to judgment as a matter of law.

The District Court carefully reviewed the facts of the case and the applicable law. As to the defamation claim, the court held no evidence was presented that William established a genuine issue of material fact that he was injured by the nursing supervisor’s documentation. In fact, the court opined the only evidence presented concerning the defamation claim was “his own self-serving statements that his reputation was denigrated as a result of the allegedly defamatory statements.”

William asserted in his breach of contract claim that he brought it in his capacity as Harold’s guardian. However, the court opined no evidence was presented that he acted in any other capacity than a concerned family member. As a result, this claim fails as a matter of law.

Court issues judgment

In his Interference with Contract claim, William proclaimed because he was a guardian for Harold, he had a contract with the Iowa District Court and the hospital interfered with the contract by communicating ex parte (without him knowing or being there) with the court.

This ex parte communication caused the court to deny his request to transfer Harold to a different hospital. However, as the court discussed, such a claim (assuming a contract existed) requires the party suffered damage because of the other party’s interference. The only assertion by William was “[the events] weighed heavily on [his] heart.” The court held this claim must also fail as a matter of law.

The court granted the hospital’s Motion for Summary Judgment.

This case illustrates the important principal that the judicial system is open for any and all to file a lawsuit. There is no predetermined screening as to a lawsuit’s merits prior to the filing of a case. The case also elucidates another principal of the law: One must be able to prove his or her case in order to obtain a judgment in his or her favor.

Also, the significance of the two nurses’ conduct cannot be understated.

The nurse caring for Harold contacted her supervisor once she discovered what William had done. The nursing supervisor immediately intervened, acted professionally during the intervention and documented the situation factually and completely.

Clearly, this evidence provided the basis upon which the case was decided.

Take these courses on proper charting and communication practices:

Document It Right: A Nurse’s Guide to Charting
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From the earliest beginnings of the nursing profession, nurses have carefully recorded their observations of patients and their interventions to help patients recover from illness and achieve optimal health. In the beginnings of the profession, the primary purpose of nurses’ notes was to verify that physician orders were completed. Today, professional nurses are vital partners with other healthcare professionals, and nursing documentation is an essential part of comprehensive patient care. Although documentation has always been an important part of nursing practice, the increasingly complex healthcare environment, litigious society and the diversity of settings in which patients receive care require that nurses pay more attention to documentation. The computerized patient record has become standard practice, and the days of repetitive task-oriented narrative notes are becoming part of nursing history.

Lines of Communication
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