▪︎ Failure to Document Nursing Care
We’ve all heard the adage “If it’s not documented, it wasn’t done.” This is a result of the fact that if a nurse doesn’t document the care and treatment he/she provided to the patient, it may appear as if the care was not provided – even though it was provided. The failure to provide care is a frequent allegation in lawsuits against nurses. The following case was recently filed and is a good example of the documentation issues that can arise.
Case: Family Alleges Negligence Against Nursing Facility Following Mother’s Death
The Petition in this case accuses a nursing and rehabilitation facility of gross negligence leading to the death of a resident. The Plaintiff was admitted to the facility for long-term care following a stroke that required a tracheostomy and PEG tube placement.
The lawsuit claims that despite orders from the facility’s primary physician for specific respiratory treatments including tracheostomy suctioning and oxygen, these were not documented or followed through with according to the Plaintiff’s medical records. The Petition states: “[T]here is no documentation or evidence in [Plaintiff’s] chart that these orders were implemented.”
The lawsuit has been filed in Harris County, Texas, accusing a nursing and rehabilitation facility of gross negligence leading to the death of a resident. The complaint was lodged by Laquishua Johnson on October 17, 2024, against Cambridge Medical Investors, LLC doing business as Gardens Terrace at Houston Nursing and Rehabilitation, and Life Care Centers of America, Inc.
Laquishua Johnson, representing herself individually and as the representative of her late mother Mary Johnson’s estate, filed the lawsuit alleging severe lapses in medical care at Gardens Terrace. According to the petition, Mary Johnson was admitted to the facility on September 30, 2022, for long-term care following a stroke that required tracheostomy and PEG tube placement. The lawsuit claims that despite orders from Dr. Acevedo, the facility’s primary physician, for specific respiratory treatments including tracheostomy suctioning and oxygen application, these were not documented or followed through in Ms. Johnson’s records. “There is no documentation or evidence in Ms. Johnson’s chart that these orders were implemented,” states the petition.
The lawsuit details numerous failures by Gardens Terrace staff to provide adequate care. It accuses them of not maintaining consistent medical records or coordinating care effectively among healthcare providers. It further alleges that staff failed to recognize signs of respiratory distress and did not implement necessary interventions timely. On October 21, 2022, Ms. Johnson was found in respiratory distress and transferred to Memorial Hermann Hospital where she later died due to complications arising from alleged negligent care at Gardens Terrace.
The plaintiff argues that these actions constitute medical negligence under Texas law. The suit also charges corporate negligence against Life Care Centers of America for failing to ensure proper staffing levels and training at their facilities which directly impacted patient care quality.
Laquishua Johnson is asking for damages exceeding $250,000 but not more than $1 million as allowed by Texas law. She demands compensation for physical pain endured by her mother before death as well as funeral expenses incurred thereafter.
Lessons Learned: Take the time to document the care you provided. If you turned the patient every 2 hours then document this (better yet, document the time when the turns were done if this is not noted in your EHR).
If you had a telephone conversation with the patient’s physician document specifically what you told the physician. For example, advised physician patient’s HR was 145 or patient’s potassium level came back at 6.2.
If you’d like to read more about the legal standards for nursing documentation and my tips to avoid problems with your documentation check out my 3 hour online video course: Documentation – When, What, and How Nurses Need to Document. (3.0 CE Hours). The course also includes extensive written materials. Here’s the link: https://nursinglawcenter.com/nursing-law-courses/
Happy Nursing!
Sincerely,
Laurie R. Elston
Nursing Law Center
www.NursingLawCenter.com
Law Office of Laurie R. Elston Inc.
📞 T: (805) 481-1001
📧 Email: Elston@charter.net
