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Liability Landscape

March 1, 2006
by Linda Williams, RN
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The Case of the Noncompliant Resident by
    Have you ever had a resident refuse to follow his or her care plan and instead make an alternative choice that you and your staff felt was risky? Maybe you've had disagreements with a resident who only wants to bathe once a week, eats food that is contrary to his or her prescribed diet, or insists on using a cane for support instead of a wider-based walker. These are dilemmas that every healthcare provider faces from time to time.

When these clashes occur, it is important for management to take action in order to protect both the resident and facility. The following is a situation in which a nursing facility's staff encountered such a resident, and the facility was later sued for a poor outcome resulting from a series of poor choices. Please take the time to review the circumstances surrounding the situation and make changes as appropriate in your facility.

The Situation
A middle-aged woman with diabetes and resulting peripheral neuropathy stepped off a curb and fractured her left foot. Since her foot had no feeling, she continued to walk on it, and Charcot's foot developed, which warped the shape of her foot from her bones disintegrating. Soon after, a skin lesion developed and an infection set in, which took a month to resolve with aggressive antibiotic treatment. Four months after the accident, she had her fracture surgically repaired by open reduction internal fixation, fusion, and grafting.

Her physician put on a total-contact cast, which was molded to the shape of her foot. The cast allowed her ulcer to heal by distributing weight and relieving pressure. Because of her Charcot's foot, the cast controlled her foot's movement and supported its contours as long as she didn't put any weight on it. For the total-contact cast to be effective, she needed good blood flow in her foot, which required careful monitoring by a professional. The woman was alert and oriented and could make her own decisions, so she agreed to accept her physician's advice and go to a local nursing facility for therapy and nursing care until she could become independent enough to return home.

At the nursing facility, the woman was instructed to keep her injured left leg elevated while in her wheelchair and bed. The physical therapist would teach her how to use crutches and do pivot transfers using her right foot while bearing no weight on her left foot. She was to receive a strict diabetic diet, as she was insulin-dependent and not very stable. In fact, a month before the fracture, she had been hospitalized for a coma related to ketoacidosis that lasted eight days. She also had a history of alcohol abuse.

The woman was very pleasant and acknowledged an understanding of her responsibilities and care at the nursing facility. However, the day after she arrived, the evening nurse noticed some blood spots on the woman's cast and on the floor in her room. Apparently, she had taken a shower, and the nursing assistant reported that she was observed partially bearing weight on her left foot despite the aide's protest. The nurse reminded the woman why she shouldn't bear weight on that foot and notified her physician of the bleeding. The woman had good circulation, so the physician asked the nurses to continue to monitor it.

Two days later, the woman left the facility at 7:00 a.m. to visit her family and didn't return until 10:30 p.m. Upon her return, she complained that her left foot was swollen and the cast was "too tight." The nurse applied ice to the cast, encouraged her to keep her foot elevated, and gave her a pain-relieving medication. The nurse warned the resident that her insurance might not pay for her care if she continued to leave for long periods of time, and the woman acknowledged her understanding.

Despite the warning, the woman continued to leave the facility for visits home or to see her family for two to twelve hours almost daily. On the ninth day of her stay, she returned to the facility in the late evening and told the nurse that she had been driving her car when it got a flat tire. When she got out of the car to check it, she stepped in some water and got her cast wet. The nurse examined the cast and found that it was soft at the bottom, with a slight tear. The nurse taped the tear and questioned the woman about the safety of her driving. The woman said that she would not do it again.

Three days later, the resident returned late from yet another family visit and told the nurse that her blood sugar would be high, as she had been drinking several beers that evening. She was right, and the nurse gave her enough insulin to provide adequate control. This was not the first sign of dietary noncompliance, as she frequently ate lunch and dinner outside the facility and often had to be given insulin upon her return. Both the nurses and dietitian had tried to reason with the woman about the need for dietary compliance, but to no avail.

Another noncompliance issue that the nurses encountered was that the woman would sometimes forget to bring her medications back to the facility when she returned from her outings. As a result, the nurses had to order duplicate medications so they would have enough to give her at the facility. Again, the nurses tried to discourage her outings, and finally she agreed to have her family visit her at the facility instead.

During the next few days, the circulation in the woman's foot remained good, although she was occasionally observed to bear weight on her left foot while walking or transferring. When confronted, she always responded that she had "forgotten."

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