PRINTER-FRIENDLY VERSION
Lessons from Litigation
Speech Language Pathologists
Facts of the Case
Muriel Boggan was a resident of a nursing home who weighed 97 pounds. She had difficulty swallowing, so a speech language pathologist (SLP) recommended a pureed diet. She indicated that all foods that were fed to Muriel were to be the consistency of pudding. According to one expert witness, the documentation was imperfect. She noted that “Assessment is hard to read, charting lined through, no information regarding medications, labs, diet order, percent of intake, type of supplements, clinical physical nutritional assessment, family conferences and meetings with care team were noted. Risks for aspiration and nutritional status were not noted.”
Contrary to the recommendations of the SLP, Muriel was given a doughnut on December 28, 2009. She choked on the doughnut and died. According to the pathologist (Dr. Brown) who performed an autopsy, Muriel "died as a result of asphyxia due to choking on food." Dr. Brown also noted that no other immediate causes of death were identifiable through the autopsy or the medical records.
Suit was brought against the nursing home for negligence based on alleged inadequate hiring, inadequate staffing, inadequate training, inadequate record keeping.
Commentary
There are two primary aspects to a swallowing study: (1) performing it appropriately, and (2) conveying the recommendations to the staff members who need to know about them and how they affect the patient’s care. The dispute in this case was not about whether the test was done properly. One may assume that it was performed appropriately, or that would have been an issue in the case.
The problem in this case was the transmission of information from the SLP to the staff members who needed to be aware of it. In the hospital setting, that would include nurses, patient care technicians, dietitians and food service workers. In the long-term care setting, certified nursing assistants, dietitians and food service workers. In the home health setting, that would include the in-home caregivers and the nurses who oversee them. Whoever gave the doughnut to Muriel should have known that she was not supposed to have solid food. It is unclear how that lapse in communication occurred, but it appears that the documentation in Muriel’s record was sub-par, to say the least.
Lessons Learned
There are certain things that should be prominently displayed in any record so that caregivers can become aware of them without digging through the chart. This generally includes a problem list, a medication list, allergies to medications, dietary restrictions and requirements for safe transfers. The entity may be negligent for implementing systems that allow these things to be buried in the chart. These things should be so prominently displayed that any staff member who was unaware of them was negligent in providing care. However, it is inappropriate to discipline a busy and hard-working staff member who doesn’t have the time to read every page in the chart before giving care.
Communication is the life-blood of health care. Even the most highly qualified caregiver will fail if not provided with all necessary information. Documentation is a channel of communication, and its failures inevitably lead to patient harm.
Silsbee Oaks Health Care v. Melancon, No. 09-12-00293-CV (Ct. App. Tex. October 25, 2012)
