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J. Lynn Case
Case Summary Sample Report
MasterFile Software
January 16, 2012
Printed 6:04 PM 16.Jan.2012
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Statement of Confidentiality
The content may be entitled to further protection from disclosure under the attorney- client privilege. Any recipient therefore, shall take all steps necessary to maintain the confidentiality of this document and its content and shall not act in any manner that compromises the privilege or protection that attaches hereto, nor waive nor abrogate the Printed 6:04 PM 16.Jan.2012
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Contents
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Issue List
Negligence - Failure to Maintain Adequate Airway Failure to Order Childlynn to be suctioned every 4 hoursFailure to Order CPT every 4 hoursFailure to Order CPT every 4 hours - Failure to suctionFailure to Order Therapist to wake Childlynn for CPT treatments to assure mobilization of secretionsFailure to Order Therapist to wake Childlynn for CPT treatments to assure mobilization of secretions - Failure to perform CPT Discontinuation of IV maintenance fluids 15 hours before Childlynn left Memorial Hospital on transportFailure to order adequate volume of IV maintenance fluids based on Childlynn`s weight Failure to Contact MD of Significant Chg in Pt. Status Failure to notify MD re continued labored breathingFailure to notify MD re retractionsFailure to notify MD re RR > 40Failure to notify MD re significant HR increase Failure to report symptoms indicating Childlynn`s unstable condition Negligence - Failure to Maintain Adequate Ventilation and Oxygenation Failure to assess Childlynn`s respiratory statusFailure to assess Childlynn`s status Failure to assess Childlynn`s cardiovascular status Failure to assess Childlynn`s neuro status Failure to assess Childlynn`s respiratory statusFailure to Consult with Pediatric Intensivist or Pulmonary SpecialistFailure to Order ABGsFailure to Order Continuous Pulse OximetryFailure to Order Repeat ABGs Printed 6:04 PM 16.Jan.2012
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Failure to report O2 Saturation level equal to or < 90% to Physician Negligence - Failure to Stabilize Childlynn`s Condition Prior to Tranport Failure to assess Childlynn`s cardiovascular status - prior to transportFailure to assess Childlynn`s neuro status - prior to transportFailure to assess Childlynn`s respiratory status - prior to transportFailure to assure staff transporting Childlynn were certified in Pediatric ACLS or PALSFailure to expedite transfer of ChildlynnFailure to recognize necessity to transfer by air with skilled medical and nursing staffFailure to stay with Childlynn on 8/12/92 to personally assess her status and prepare her for safe transfer Printed 6:04 PM 16.Jan.2012
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Players (Cast of Characters)
Provided Ground Transportation for J. Lynn from Memorial Hospital to BCH Receiving physician at Beard State Hospital RT 11pm-7am Shift 8/10/92 and 8/11/92 at Memorial Hospital RT on 7am-3pm Shift 8/11/92 and 8/12/92 at Memorial Hospital Paramedic for Beard County Ambulance Services RT on 3pm-11pm Shift 8/11/92 at Memorial Hospital Air Transport Services available but not used to transport J. Lynn Hospital facility initially caring for J. Lynn RN on 3pm-11pm Shift 8/10/92 at Memorial Hospital Vice President of Nursing (Nurse Administrator) at Memorial Hospital RN on 11pm-7am Shift 8/10/92 and 8/11/92 at Memorial Hospital RN on 7am-3pm Shift 8/11/92 and 8/12/92 at Memorial Hospital Printed 6:04 PM 16.Jan.2012
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Pathologist for Beard State Coroner's Office Printed 6:04 PM 16.Jan.2012
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Case Chronology
Trahan notes indicate Lynn's Mother and Father clearly identified the need for immediate transfer.
Trahan notes Lynn was Flaccid and Jerking behavior, Trahan's documentation clearly indicates Dr. Brown is aware that Lynn's condition was getting worse. Record clearly indicates a prolonged delay in expediting transfer. Dr. Brown documented HR in 120s. Dr. Brown did not document assessment of circulatory status. Did document a repeat ABG in Progress Notes but no other ABGs to be done prior to transport.
Dr. Brown document presence of coarse rhonchi and basilar rales. Dr. Brown also documented increased HR in 120s.
Dr. Brown ordered O2 via mask at 6 liters/min. and O2 Saturation, Pulse Oximetry and ABG in 30 minutes if O2Sat < 90%. Dr. Brown ordered IV started with D5W at 30cc/hr.
Per Dr. Brown's orders, D5W IV 120cc to be delivered.
Trahan documented HR 166. No indication that Dr. Trahan does not document D5W IV delivered.
White documented ABG revealed severe hypoxemia.
Trahan's late entry indicates Dr. Brown was contacted. Strongly for Us Documentation does not include what was communicated to Dr. Brown or if any new orders were given.
Trahan late entry noted indicates Dr. Brown called Printed 6:04 PM 16.Jan.2012
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regarding O2Sat of 74%. No new orders noted.
Entry appears to have been written by 7a-3p nurse Trahan and does not include respiratory assessment or notification of D. Brown.
Trahan did not document D5W IV delivered due to Dr. Brown's order to DC IV fluids 8/11/92 at 21:10.
No IV Fluids delivered, due to Dr. Brown DC of IV Dr. Henry reported CXR reveals worsening Green documents D5W 90cc IV delivered.
Per Dr. Brown's orders D5W IV 180cc to be delivered.
Trahan documented, RR 60 with retractions. No documentation of respiratory status in nursing notes noted.
Dr. Brown ordered Solu-Medrol and ordered Lasix Trahan documented, Lynn with Labored Breathing with retractions on 30% O2 per Mist Tent.
White documented, Lynn continues retracting.
Trahan stated in notes, Lynn continues retractions with To decide Per Dr. Brown, 240cc of D5W IV was to be delivered Joseph documented ChildLynn still retracting even Printed 6:04 PM 16.Jan.2012
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with RR 32 and with 30% O2 per Mist Tent.
Joseph documented Lynn still retracting even with RR Lewis indicates Mist Tent started at 03:30.
Lewis noted Mist Tent ordered to be started after Nebulizer treatment was completed at 02:15.
Documented post nebulizer treatment originally Joseph noted RR at 48 with retractions and O2S at 82% post nebulizer treatment documented at 100%.
Joseph documented Lynn placed in warm tub.
Joseph documented RR 84 with retractions.
Joseph documented IV infiltrated. Does not document Green's notes indicate a delay starting IV for 2 hours Per Dr. Brown's orders D5W IV 240cc to be delivered Per Dr. Brown's orders D5W IV 150cc to be delivered Dr. Brown ordered D5W IV 30cc / Hr. Lynn weight was To decide Printed 6:04 PM 16.Jan.2012
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Documents by Type
IV with D5W at 30cc/hr. O2 via mask at 6 liters/min. and O2 Saturation, Pulse Oximetry and ABG in 30 minutes if O2Sat < 90% IV with D5W at 30cc/hr. O2 via mask at 6 liters/min. and O2 Saturation, Pulse Oximetry and ABG in 30 minutes if O2Sat < 90% Various orders from 10 Aug 1992 to 12 Aug 1992 Printed 6:04 PM 16.Jan.2012
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Documents by Date
IV with D5W at 30cc/hr. O2 via mask at 6 liters/min. and O2 Saturation, Pulse Oximetry and ABG in 30 minutes if O2Sat < 90% Various orders from 10 Aug 1992 to 12 Aug 1992 Printed 6:04 PM 16.Jan.2012
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