Case Study: When Standing Orders are Disregarded

Repurposed from the Scope, Medical Edition, Second Quarter 2023

Facts of the Case

A 75-year-old obese female with a history of COPD, depression, Type 2 diabetes, thyroid and breast cancer, hypertension, macular degeneration, anemia and bilateral knee replacements required revision of the right total knee arthroplasty. She first presented to the MLMIC-insured orthopedic surgeon with a complaint of worsening pain and decreased range of motion in her right knee after suffering a fall. The surgeon’s impression was aseptic loosening of the right knee prosthetic, and the plan was to perform a right total knee revision of the tibial component, though he noted that the entire knee might have to be revised.

The patient was admitted to the MLMIC-insured hospital with a diagnosis of failed right total knee replacement, on which the orthopedic surgeon performed a right total knee revision. During the surgery, it was noted that the patient had also suffered a patellar fracture, which was repaired. The patient was deemed a “fall risk,” but on the following day, while brushing her teeth in the bathroom, the patient was witnessed falling to the floor, bumping her head and sustaining an abrasion of the left middle finger. X-rays ruled out a fracture or dislocation. The patient was transferred to the hospital’s Transitional Care Unit for rehabilitation.

Five days later, a MLMIC-insured orthopedic PA issued orders for an immobilizer to be kept on the right knee. Two days later, the surgeon issued orders for the patient to wear the immobilizer when ambulating. Nursing records indicated that the patient was to be transferred from her bed to the chair with the assistance of one person and with the immobilizer in place.

Eight days post-op, the surgeon examined the patient and found the knee to be neurovascularly intact with no infection. He advised that she was to begin physical therapy that included continuous passive motion, and the knee immobilizer was to be used when ambulating. The surgeon did not replace the immobilizer after the examination. Shortly thereafter, the patient asked to use the restroom and was assisted by the CNA, who questioned whether she required the immobilizer. The patient advised that she would not require the immobilizer for the short distance to the bathroom and enlisted the help of the nursing assistant.

After toileting and attempting to pull up her pants, the patient felt her right knee buckle and heard a “pop.” Thereafter, she was seen by the MLMIC-insured hospitalist along with a first-year resident, who noted active bleeding from the wound and complaints of pain. It was also noted that she was ambulating without the immobilizer despite orders to the contrary. As the hospitalist and resident felt she may have avulsed the patellar tendon, a plan was placed for constant use of the immobilizer. X-rays were consistent with a high-riding patella due to a patellar tendon rupture.

Six days later, the patient was transferred back to the hospital, where the orthopedic surgeon repaired the right patellar tendon rupture using an allograft. A complete disruption of the patellar tendon was noted. Post-op, the patient was maintained on IV antibiotics and was noted to have some drainage and erythema of the surgical site. Blood and wound cultures were negative, though a wound infection and cellulitis were suspected. The patient was afebrile with stable vital signs throughout the entire admission; however, the knee remained swollen and red with a one-by-one-inch eschar at the lower portion of the wound. Broad-spectrum antibiotics were prescribed due to the infectious disease consult’s suspicion of wound infection.

After 3 weeks on antibiotics, the patient received 9 days of hyperbaric oxygen treatment. Gram stain showed no organisms and no elevated white blood count; the culture did not grow anything, and the antibiotics were discontinued after five weeks.

One week later, the patient was seen by the orthopedic surgeon, who noted that subsequent X-rays revealed a new patellar tendon rupture. He speculated that the patient had completely ruptured the tendon. The plan was to obtain a second opinion and further reconstructive surgery at another hospital.

Two days later, the orthopedic surgeon tapped the knee, and 10 cc of blood-tinged clear fluid was obtained. The fluid revealed glucose of 126, which was normal due to the patient’s diabetes. The WBC was 2,570, which was low for the indication of infection.

A wound culture the following day showed sparse budding yeast, and the culture revealed Candida albicans. The sutures were later removed, and although some drainage was noted, everything appeared to be stable. The patient was examined by a wound care physician, who found no further need for the hyperbaric treatment as her pain had improved significantly and the knee was essentially healed, with only a small scab at the wound site.

As Medicare would not approve another week in the Transitional Care Unit prior to transferring to the new hospital, the patient was transferred to the MLMIC-insured rehabilitation facility. Records and documentation accompanied the patient, indicating the importance of checking the right knee for signs of infection.

A MLMIC-insured internist was the patient’s attending physician during the week she was admitted to the facility, and his orders included that dry protective dressings were to be applied to the right knee each day after cleansing with normal saline, the right knee brace was to be applied and occupational and physical therapy performed. Lab work was to be completed, and the physician was aware that the patient had been off antibiotics for 2 weeks and was to be off them for 3 weeks prior to her pending knee repair surgery. The patient’s vitals were recorded three times daily.

On her second day of admission, the nurses noted the patient’s skin integrity to be “intact,” and her labs revealed elevated white count and platelets. On subsequent days, the patient complained of increased pain in the right lower extremity. In addition, she developed a fever, and red and yellow drainage was noted on the right knee. The internist was called, and he gave orders to elevate the leg and administer Tylenol. By the following morning, the patient’s fever was subsiding, though she continued to complain of pain as she was transferred to the hospital.

At the subsequent hospital, the patient was seen by an orthopedist, who noted the right total knee arthroplasty to be infected. His exam revealed lymphedema in the bilateral lower extremities. The surgeon advised the patient that the options were above-the-knee amputation or an attempt to salvage the leg with a graft. He then admitted her to the ER for an infectious disease consultation, IV antibiotics and aspiration of the knee. He planned to wait one week and then resect all components.

After a 6-week admission, the surgeon performed complex reconstructive surgery and knee fusion with a long intramedullary rod. Post-op, the patient was noted to have a well-healed incision and was ambulating in rehab using a walker.

The patient subsequently complained of left knee pain after slipping off the toilet and had chronic falls due to balance issues. The right knee remained unchanged; however, the fusion resulted in a one-inch shortening of the right lower extremity.

As a result of her initial injury and cascading events thereafter, the patient brought a lawsuit and sought monetary damages from the defendant hospital for being allowed to ambulate to the bathroom without her right knee immobilizer following her total knee arthroscopy.

This case was reviewed by experts in orthopedics and internal medicine, who found a departure in the standard of care for our insured hospital as the CNA failed to follow the physician’s orders to utilize the immobilizer, resulting in the patient’s fall and the resultant tendon rupture. A nursing consultant agreed that the CNA deviated from following standing physician’s orders and adhering to the Safe Program.

The case was eventually settled on behalf of the hospital.

A Legal and Risk Management Analysis

The failure of the MLMIC-insured surgeon’s CNA to put the brace back on before allowing the patient to ambulate was the precipitating cause of the negative outcome. As far as the CNA knew, the order to wear the brace at all times was still in place. When she encountered the patient without the brace, it was her obligation to ensure the patient understood and complied with the doctor’s instructions. Unfortunately, the patient misunderstood the doctor’s instructions, and the CNA’s wrongful reliance on the patient’s understanding compounded poor decision-making. When a patient’s failure to understand physician instructions contributes to an incident, as it did here, assessment of the communication is important.

Instructing the patient on the proper use of her immobilizing device was crucial to avoiding further injuries or complications. Had the patient fully understood, she would not have presumed it was acceptable to ambulate, squat and extend her knee while bearing weight without the brace. This is not to assign blame to the patient or physician in this case. The CNA should have known better. However, effective patient/provider communication and patient engagement may have prevented reinjury.

This case demonstrates why open and clear communication throughout the course of care is critical, particularly with this elderly patient. Communication errors put patients at risk of injury. Hospitals that fail to have in place, enforce and train on best practices for communication and health literacy in the elderly patient population are at risk of medical malpractice.

MLMIC policyholders can reach out to our legal department for questions regarding communication or to inquire about any other healthcare law issues by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.

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This document is for general purposes only and should not be construed as medical, dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical, dental or professional obligations, the applicable state or federal laws or other professional questions.