Woman dies waiting to be seen, ED nurse to be sued — Are you at risk?

Case is wake-up call for emergency nurses

It may sound unthinkable: Emergency nurses ignoring a woman's pleas for help as she bleeds to death on the floor of their waiting room. But that is what the family of a Los Angeles woman claim happened on May 9, 2007, in the ED at Martin Luther King Jr. — Harbor Hospital.

According to a report released by the Centers for Medicare & Medicaid Services, six ED staff members failed to assist the woman, who died of a perforated bowel. The hospital was cited for violating the Emergency Medical Treatment and Labor Act, and the family has announced they will file a wrongful death and medical malpractice lawsuit against the hospital and the ED nurse involved.

Although all the facts of this particular case are unknown, it has sounded an alarm for emergency nurses caring for increased volumes of sicker patients.

"Almost every ED has times when overcrowding is a concern. This case does increase my concerns of an overcrowded waiting room," says Marianne Fournie, RN, BSN, MBA, corporate director for emergency services at Methodist LeBonheur Healthcare in Memphis, TN.

Crowding, a nursing shortage, an increasingly elderly population, and a growing number of underinsured or uninsured patients has pushed many EDs to the very edge of their capacity, says Donna L. Mason, RN, MS, CEN, nurse manager of adult emergency services at Vanderbilt University Medical Center in Nashville, TN, and president of the Emergency Nurses Association. "Crowding does contribute to the risk of adverse outcomes, and in my opinion, the risk of liability for all the health care professionals in the ED including the triage nurse," she says.

Whatever the facts of this particular case, an incident such as this "must serve as a wake-up call," according to Mason. "Every incident that gets into the news media is of concern to each and every emergency nurse who has the responsibility of triage and the waiting room," she says. "We are all concerned about liability. But more than liability, we are concerned that patients are not getting the care and attention they need for their illness or injury."

Whenever a sensational ED case hits the media, it's not unusual to see the "blame game" played out, says Mary Ann Shea, JD, RN, a St. Louis-based registered nurse, attorney at law, and former emergency nurse. "The finger has been pointed pretty directly at the triage nurse," she says. However, the facts can only be evaluated by spending time talking to all who were involved, and it takes time to complete such an investigation, Shea says. "I doubt that this case is as simple and clear cut as it sounds when presented on the news," she says.

What is clear, however, is that all triage nurses must follow ED policies and procedures for triage, identify patients with potential life-threatening conditions, and then ensure that those patients are seen as soon as possible, says Shea. "How do we define the term 'possible?' It depends on what else was going on in the ED at the time and how many staff were available," says Shea. "There are too many unanswered questions to warrant anyone passing judgment at this point."

Suit to raise awareness

Whether the nurse and hospital are found liable for wrongful death, ED nurses might be more likely to be sued for "overlooking" patients, notes Shea. "Anytime there is a high-profile case such as this one, it encourages others to consider these types of issues if the fact scenarios mirror this case," she says. "It also raises awareness of issues that others might not have considered before hearing about a case like this."

It has become fairly common for individual nurses to be named in lawsuits, especially if they have played a prominent role in the patient's care, according to Kathleen A. Catalano, RN, JD, director of health care transformation support for Perot Systems, a Plano, TX-based provider of information technology services and business solutions, and a former ED nurse.

"We see this in the intensive care unit and the perioperative areas; I'm not surprised to see it in the ED," she says. "I believe the liability risks will continue to increase if overcrowding in waiting rooms is not addressed."

To reduce legal risks, do the following:

Be sure that all patients are reassessed in the waiting room.

At Methodist LeBonheur, a computerized tracking and documentation system reminds nurses to record patients' vital signs every two hours. "Reassessment includes rechecking vital signs and obtaining a statement of the patient's condition for Emergency Severity Index levels two and three," says Fournie. "If anything has worsened, the triage level can be changed."

In addition, triage areas were moved within the waiting room to give the nurse a full view of the waiting area so that patients with worsening conditions can easily be seen, says Fournie.

Other EDs have paramedics or technicians in waiting areas to ensure patients are being watched and attended to, says Mason. "This observation is noted on the ED record or nurses notes, along with other pertinent information for a particular condition," she says.

Document reassessments.

If a patient's initial symptoms are worsening, fully document this to protect yourself legally, says Catalano. "Include a statement regarding the fact that the physician was advised and his/her response," she says. "Make sure the chain of command is well known and followed."

Consider creating a separate form to document reassessments and list the patient's name, signs and symptoms, vital signs, and time of the assessment and reassessments, advises Catalano. Documentation in the medical record is the only way you can prove that you assessed and reassessed a patient, emphasizes Shea. "Failing to document it raises a presumption that it was not done," she says. "It is highly unlikely that a nurse can convince a jury that an action was performed when it is not documented in the medical record."

Use objective documentation — what you see, hear, smell, or touch — instead of subjective documentation such as "patient doing better," or "patient is stable," recommends Shea. "Neither of these comments communicates information sufficiently for another person to get a picture of the patient's condition," she says.

Shea gives two examples of objective documentation that clearly communicate a patient's condition: "Patient states his pain has gone down from 7 to 2 on a scale with 10 being the worst," and "patient's lips are cyanotic, and she is guarding her abdomen and grimacing in pain."

"Describing a patient's skin coloration, posturing, and facial expressions gives the reader a much clearer picture of what is happening," she says.

Keep charge nurse informed.

The triage nurse must inform the charge nurse about patients needing to come in immediately, even if no beds are available, says Mason.

"Because of the large number of patients without health insurance, EDs see a lot of people who have waited until the last minute to seek help, and often times they are quite sick," she says. "EDs need to have an experienced person out in triage to wade through the sick, sicker, and sickest."


For more information on reducing liability risks of crowded waiting rooms, contact:

  • Kathleen Catalano, RN, JD, Perot Systems, Healthcare Transformation, 2300 W. Plano Parkway, Plano, TX 75075. Phone: (214) 709-7940. E-mail: kathleen.catalano@ps.net.
  • Marianne Fournie, RN, BSN, MBA, Corporate Director, Emergency Services, Methodist LeBonheur Healthcare, 251 S. Claybrook, Suite A218, Memphis, TN 38104. Phone: (901) 516-2357. Fax: (901) 516-2676. E-mail: fournieM@methodisthealth.org.
  • Donna L. Mason, RN, MS, CEN, Nurse Manager, Vanderbilt University Medical Center, Adult Emergency Services, 1211 Medical Center Way, Room 1314, Nashville, TN 37232-7240. Phone: (615) 343-7223. Fax: (615) 322-1494. E-mail: donna.mason@vanderbilt.edu.
  • Mary Ann Shea, JD, RN, Attorney at Law/Registered Nurse, P.O. Box 220013, St. Louis, MO 63122. Phone: (314) 822-8220. Fax: (314) 966-0722. E-mail: masheajdrn@aol.com.