Do I have a case? PEG tube misplacement

[rmet4nzkx]

If after consulting several attorneys it seems that the case is not cost effective to prosecute, you can not only place a complaint against the nursing facility but also file administrative complaints against the nurses and doctors with their respective licensing boards, there is no cost for that and they will examin the medical records and determin who failed to meet the standard of care..

 

[ellencee]

Thanks again for great information. Few questions... Do I have the right to ask for the manual of procedures? Is this public information, or would the state Medicare have this, or only the state information? I see your note regarding keeping my expectations reasonable. To be completely honest, it is not about the money to me - I know that people say that all the time, but it really is not. I would be donating to MDA. I am curious though if the cost of the lawyer, etc would be worth the type of claim I would make. Does this make sense? I know that noone would be able to say what amount, but expectation wise what range? In the event that the lawyer did not take the case based on a % of payout - I am also facing having to pay the 2000-2500 charge for the medical review. I just cant afford to put too much into this without at least recovering what I put in. I will pursue the complaint regardless, but just cannot determine what I am looking at as far as what I will be charged and if it will be worth it. At the same time, it is hard to place a monetary value on any of it to me.

Your attorney will obtain copies of the nursing home records, the nursing home's policy and procedure manual, and the hospital records. The attorney can save money by requesting the table of contents from the nursing home's policy and procedure manual, identifying the sections needed, and requesting copies of those pages instead of paying for a copy of the entire manual. Be sure to request the RNs employee files, the nursing logs for the day of the incident and at least a week prior to that date and for all of the days after the incident through the last day your brother was at the facility. Ask for all memos, etc. (to and from the DON and administrator, and/or the nursing home's RN educator).

You may be able to get the attorney to pay for the expert review if you print out the entire article that I referenced. I found several articles that support your claim and if you have your private messaging on or will provide an email address, I will be glad to send you the links to the additional articles.

A key point is that one does not start feeding through a PEG tube until one has verified placement. Nursing homes do not have equipment necessary to verify placement of a PEG tube. A reasonable and prudent RN would not initiate feedings or give meds through a PEG tube until placement had been verified by radiology. (Checking for pH of aspirated contents can be used to check placement but nursing homes don't have the necessary testing materials and pH testing can not tell you if the contents came from the peritoneal cavity or the "stomach".)

Another key point is that when a PEG tube is pulled out by the patient, chances are great that at that time, stomach contents spilled into the peritoneal cavity and even correct tube replacement cannot and does not identify or correct perionitis that occurred from the spillage of stomach contents into the peritoneal cavity when the tube was pulled out. Again, x-rays are needed to either confirm spillage into the peritoneal cavity or rule out spillage into the peritoneal cavity.

Even board-certified gastroenterologists who replace a PEG tube at the bedside (or insert a catheter to keep the stoma open) follow-up with an x-ray; it is the standard of care.

As for the amount for which you should sue, that will be determined once the attorney evaluates the aspects of the claim. That will require reviewing all of the records and gaining expert opinion on several aspects. Your claim will require an RN expert's review of the records and subsequent expert opinion. Your claim will require an expert review of the records by a physician who provides the same type services as the nursing home's physician, which will be less costly than the next expert you will need...the enterologist. An enterologist of the same type that inserted the PEG tube for your brother's care will be needed to review the records and opine. $3-5K is a reasonable (low) estimate for the expert reviews.

As for your statement about not wanting "the money": you need to change your attitude. If you are in this for the long-haul, you had better be thinking 'they will pay for what they did to my brother' or you won't make it through the process.

Nursing homes don't have as many defense resources as do major hospitals, so I am kind of anticipating this not being as aggressively defended as if you were up against a hospital.

I forgot to add one other thing. The nurse did check with the doctor - she faxed to him when the tube came out initially. The fax states... "Pulled out G-tube today. Replaced 15fr/5cc foley cath is this ok or should we send over to gastrointerology to replace on he already had? Call ASAP" The doctor's written response on the fax is "OK to try - thanks"

I think this is a great piece of evidence for your side. The nurse KNEW she shouldn't be responsible for PEG tube replacement and verification of the tube's being properly placed or she wouldn't have questioned her actions. The physician's response was idiotic. "OK to try" when the nurse told the MD she had already replaced the tube with a foley. The physician did not even answer the question about sending the patient over to gastroenterology.

I think you have a "slam dunk" claim.

EC

 

[panzertanker]

I am missing something here:

"I forgot to add one other thing. The nurse did check with the doctor - she faxed to him when the tube came out initially. The fax states... "Pulled out G-tube today. Replaced 15fr/5cc foley cath is this ok or should we send over to gastrointerology to replace on he already had? Call ASAP" The doctor's written response on the fax is "OK to try - thanks"

This reads to me that they placed a foley into the stoma and then faxed the request. NOT that they put in a button....
WHO replaced the PEG tube, was it the same size, and what documentation is there regarding verification of placement?

xray will verify placement of tube, but unless I am mistaken (and I have been from time to time) xray is NOT going to show spillage of gastric contents in the peritoneal cavity. (unless they are adding a radiopaque element to the hyper alimentum now-a-days).

 

[ellencee]

I am missing something here:

"I forgot to add one other thing. The nurse did check with the doctor - she faxed to him when the tube came out initially. The fax states... "Pulled out G-tube today. Replaced 15fr/5cc foley cath is this ok or should we send over to gastrointerology to replace on he already had? Call ASAP" The doctor's written response on the fax is "OK to try - thanks"

This reads to me that they placed a foley into the stoma and then faxed the request. NOT that they put in a button....
WHO replaced the PEG tube, was it the same size, and what documentation is there regarding verification of placement?

xray will verify placement of tube, but unless I am mistaken (and I have been from time to time) xray is NOT going to show spillage of gastric contents in the peritoneal cavity. (unless they are adding a radiopaque element to the hyper alimentum now-a-days).

Silly boy...you know placement is verified with a water-soluable "dye" and that an x-ray of the abdomen should be obtained to check for free air in the peritoneal cavity and when such free air is also in the presence of fever, elevated white count, abdominal pain, deterioration of patient status, etc. that further diagnostics and interventions will be initiated to diagnosis and treat peritonitis.

This post deals with all step-one type diagnostics. A finding of free air in the abdomen would be sufficient cause to investigate further when the patient presents with signs/symptoms such as those exhibited by our original poster's brother.

You can bet your sweet bippy that if the gastroenterologist had been called, the poster's brother would have been sent to the ER for tube placement verification with water-soluable dye and that an x-ray of the abdomen would have been obtained. Heck, the foley catheter would have been removed an a 'real' PEG tube would have been inserted.

Read the article I referenced by link. The claim/violation is the same as this original poster's claim. An RN in a nursing home replaced a PEG tube, did not send the patient to the ER, the PEG tube was placed into the peritoneal cavity, feeding and meds were given via the PEG tube, the patient developed peritonitis and died. Medicare and Medicaid have specific standards of care that were not met in the referenced link or in the original poster's description of events.

Sorry if I offend, but this time, the RNs killed a patient by failing to follow standards of care and by assuming too much responsibility, which equals gross negligence and exceeding the scope of their practice. The same goes for the nursing home's phyician; the physician's negligence in failing to send the patient to the ER or to call the gastroenterologist for a consult is the direct cause of the patient's death from peritonitis. Not exactly a shining set of examples of professional behavior.

(I forgot this part of my answer--yep, you can get enteral feedings with dye and such feedings are for exactly what we are talking about, detecting spillage/leaks into the peritoneal cavity. I have only had one patient that received this type of feeding with dye and it was a multiple trauma patient with complicated sequelae.)

EC

 

[baesmile1]

Thank you again for all of your help, this has definitely made me feel as though I should pursue, and I am in it for the long haul, regardless of the outcome. Someone should take responsibility for the error which was made.

I do have a feeling though that the defense will be the same as that of a hospital due to the same company owning both hospitals in town, the nursing home, and several other establishments. When it comes to anything medical in this town, they are all the same it seems.

I have a meeting with a lawyer next Thursday that specializes in nursing home cases like this, so hopefully I will have some more to go on then. All of this information has been great. I actually already got all of the medical records, with the exception of the ambulance report, so the attorney should only need to request the remaining information.

You all have been exceptional people in helping me to better understand everything. Thank you all again, you are handling a wonderful service here of giving people the confidence to move forward and address things that need to be taken care of. I will keep you updated.

 

[rmet4nzkx]

Thank you again for all of your help, this has definitely made me feel as though I should pursue, and I am in it for the long haul, regardless of the outcome. Someone should take responsibility for the error which was made.

I do have a feeling though that the defense will be the same as that of a hospital due to the same company owning both hospitals in town, the nursing home, and several other establishments. When it comes to anything medical in this town, they are all the same it seems.

I have a meeting with a lawyer next Thursday that specializes in nursing home cases like this, so hopefully I will have some more to go on then. All of this information has been great. I actually already got all of the medical records, with the exception of the ambulance report, so the attorney should only need to request the remaining information.

You all have been exceptional people in helping me to better understand everything. Thank you all again, you are handling a wonderful service here of giving people the confidence to move forward and address things that need to be taken care of. I will keep you updated.

Even if you do sue you can still bring a complaint against the licenses of the providers at fault, but better to wait until the lawsuit is at least through discovery to write the complaints and oked by the attorney. You can request the complaint forms from the boards actually preparing a complaint can be therapeutin and help you organize the data. You will want to make copies of all the medical records you collect which is cheeper than requesting them again from the nursing home and hospital, you may also want to to an inhouse review to make sure you got everything.

 

[baesmile1]

I have filed a complaint with the VA Dept of Health. They normally do not review complaints which have extended past 12 months prior, but after talking with them, and the lady I initially talked with, talked with her supervisor and called me back to tell me that their office wanted to do a complete investigation. Do you know if they will automatically file the complaint against all of the parties involved automatically, or would I need to file separate complaints? I am not able to read the name of the nurse who signed the form, and was not familiar with all of them, there were several who were close to our family and my brother and even came to see him when they were off. I would definitely not personally send anything to them prior to the case being reviewed with the lawyer as I do not want to make any false moves. I think they may be wising up to thinking something may be happening because they have failed to contact me since my last request to have something sent to me indicating that the balance of my account is $0. The last thing I have is the $4000 + bill, but they have advised me not to make any payment. Hopefully I will get this information also, but even without there is no outstanding charge for me at this time with the company. We will see if they change anything.

I would really like to see the records from the nurse's personnell files to see if any actions were taken. I think that will be interesting, and am ready to move forward. Hopefully I will know something soon about the complaint filed, and the lawyer will be able to begin requesting additional information.

Again - You have all been wonderful! Thanks for your advice and support.

 

[baesmile1]

Update - have a lawyer

Just wanted to update everyone on the status, I met with a lawyer yesterday, and feel very good about him. He took the case and is in the process of re-requesting all of the medical records. During the consultation, his nurse assistant sat in. She previously worked as a nurse for 30 years. They have had this same type case previously with another area nursing home and were very familiar with the care and the documents involved.

In their initial review of the records, they feel as though there are missing documents. Also, in looking at what I do have - they found that in addition to my brother having peritonitis, sepsis had already set in at the time he was sent to the emergency room, so apparently he may have been fighting this for some time before with no knowledge of the infection.

We will see what happens from here and I will keep you all updated.

 

[rmet4nzkx]

Just wanted to update everyone on the status, I met with a lawyer yesterday, and feel very good about him. He took the case and is in the process of re-requesting all of the medical records. During the consultation, his nurse assistant sat in. She previously worked as a nurse for 30 years. They have had this same type case previously with another area nursing home and were very familiar with the care and the documents involved.

In their initial review of the records, they feel as though there are missing documents. Also, in looking at what I do have - they found that in addition to my brother having peritonitis, sepsis had already set in at the time he was sent to the emergency room, so apparently he may have been fighting this for some time before with no knowledge of the infection.

We will see what happens from here and I will keep you all updated.

Glad to here you found an attorney you feel comfortable with. I am not surprised that the record you have is incomplete, that is why it is good to have someone go and view the files in the facility and then request the records, it is amazing what they leave out. Keep us updated. Also in response to your last post before this one, ask your attorney about when to make the ocmplaints, if you don't know the DR/Nurses make it to the medical/nursing boarda.

 

[baesmile1]

Also in response to your last post before this one, ask your attorney about when to make the ocmplaints, if you don't know the DR/Nurses make it to the medical/nursing boarda.

I actually have already filed the complaint with the Dept. of Health, although they have not yet begun the investigation, as I did not make this until recently and it is past the 12 month period they normally investigate complaints within. Due to this, it will have a lower priority than current cases. It was actually very interesting though because at first they were not going to investigate, then they called me back and advised they wanted to do a complete investigation. I am not sure I understand your comment about the DR/Nurses making it to the medical & nursing boards.

I am very comfortable with this attorney, as even with the last case they found the records were not provided, and falsified. It seems like there is so much going on here that is not available. I am more interested than ever to get to the truth, I hope that it happens.

The other interesting thing that the lawyer told me is that in their dealings with this medical provider they have found they hardly ever relieve obligation of bills. I have been trying to get a statement of account to show the $0 balance, as the director of risk management told me not to pay anything, however, they are procrastinating and not supplying this. They saw this happen where following the statute running out, the provider turned the debt over to a collector to recover what was said not to pay.

I find this entire situation very upsetting. I cannot believe that any medical provider would act in such a deceitful way. Don't get me wrong, I am not implying that this is what will happen with me, but I cannot believe that it has happened before. I hope if for nothing else, this will give me peace in knowing that I have fought for everything I could for him.

Will definitely keep you updated, and will probably have more questions.

Thanks for everything!

 

[baesmile1]

Update and a Few Questions

Just thought that I would update everyone on where we were with this case. The lawyer has received all records with the exception of the nursing home. Once they have this they will be able to file, and interestingly enough the nurse who now works for the lawyer, recalls having a conversation with one of the nurses in the surgical intensive care unit following my brother's surgery. At the time of course, noone knew that this would be the outcome, but she remembers the nurse being extremely critical of the care he had received, and being very concerned about his condition.

How ironic, that I chose this attorney whose assistant actually is friends with one of the nurses who treated my brother following this. Definitely a sign that I am doing the right thing.

The lawyer thinks that we will be filing a claim within the next two weeks, I am very interested to see how this all goes from here. I meet with him next week to go over what the process will be like, etc.

Since I am filing this on behalf of my brother, the VA law actually directs parents as next of kin in event of a monetary settlement, the lawyer is looking into having disclaimers drawn up for my parents to sign. Does anyone know if in addition to my parents signing this disclaimer (which they have already agreed to do, since they are out of state and I have been handling on my own with the support of my husband) if my step siblings or one half brother will need to sign, or if I would automatically be named next of kin to receive the settlement in the even there was one. The lawyer was looking into it, because he has not ever dealt with this type of situation where the entire family wasn't involved. Is there a way to assign anything to me? I am the administrator, so wasn't sure.

I am hoping that this will result in an awareness in our community where there is only one major health care provider that owns the majority of the business for the health industry here, that not always are things as they seem, and it will take someone standing up and saying something in order to honor those who have suffered.

Any thoughts also on how an amount of the settlement is derived? Suggestions on determining the value of this? I wouldn't even know where to begin to determine this, but it seems as though there are very few factors indicating that this will just be washed aside, and it seems it is a definite go at this point, so I was curious about this also.

Thanks in advance for everything you have all provided, mostly just the support and kind words of advice - which have definitely helped me in being strong and standing up for my brother and his unnecessary pain and suffering. Will continue to keep you updated, and look forward to reading your responses.

 

[rmet4nzkx]

Here is a link for all of Virginis liscening boards, this is different than the board of health, so you can make complaints re both Drs & nurses etc. this is different than where you filed your complaint. Your attorney will provide your best advice re your case.
Virginia Department of Health Professions - Licensing health care providers and ... How to File a Complaint ·
http://www.dhp.state.va.us/

 

[baesmile1]

Update - Expert Witness

Just wanted to again thank everyone for all of your help with pointing me in the right direction. It has been a long and interesting road so far.

To update - the Dept. of Health finally got to my complaint and came into the facility that has now assumed the smaller facility to conduct their investigation. Somehow the investigation was being listed as only against the current facility, not that of the larger company that manages the health care, therefore when they asked for my brothers records, they were denied due to him never being a patient there. Understandable.

As for the case with the lawyer, the suit has been filed and we are just waiting on confirmation from at least 1 of 4 doctors (Medical Experts) to confirm the negligence. The lawyer actually has a meeting with the best qualified of these on Thursday. I am hoping this will allow us the "go" to go ahead and serve the case. Then I am sure things will seem to be a little faster and it will actually be moving ahead.

I have been amazed at the difficulty in finding an expert witness that has been faced. I understand the significance of having the expert, but when a provider is so large and throughout the state, it has been difficult. The expert that the lawyer has ready to review with is a professor at a well known university that specializes in PEG tubes and nutrition associated with these. I am hoping he will be the one we need.

Thanks again for all your help. I will continue to keep you updated, I find this site extremely interesting so frequent it often. In addition, I also posted about the issues I was having with my husband and his ex-wife, now he is on the way to becoming my ex-husband also... Divorce will be filed December 5th...

 

[ellencee]

Just wanted to again thank everyone for all of your help with pointing me in the right direction. It has been a long and interesting road so far.

To update - the Dept. of Health finally got to my complaint and came into the facility that has now assumed the smaller facility to conduct their investigation. Somehow the investigation was being listed as only against the current facility, not that of the larger company that manages the health care, therefore when they asked for my brothers records, they were denied due to him never being a patient there. Understandable.

As for the case with the lawyer, the suit has been filed and we are just waiting on confirmation from at least 1 of 4 doctors (Medical Experts) to confirm the negligence. The lawyer actually has a meeting with the best qualified of these on Thursday. I am hoping this will allow us the "go" to go ahead and serve the case. Then I am sure things will seem to be a little faster and it will actually be moving ahead.

I have been amazed at the difficulty in finding an expert witness that has been faced. I understand the significance of having the expert, but when a provider is so large and throughout the state, it has been difficult. The expert that the lawyer has ready to review with is a professor at a well known university that specializes in PEG tubes and nutrition associated with these. I am hoping he will be the one we need.

Thanks again for all your help. I will continue to keep you updated, I find this site extremely interesting so frequent it often. In addition, I also posted about the issues I was having with my husband and his ex-wife, now he is on the way to becoming my ex-husband also... Divorce will be filed December 5th...

I admire your guts to hang in there! I want you to give the following information (from an earlier reply by me) to your attorney. I also want you to remember that a physician cannot review the work of a nurse; only a nurse can do that. Your claim will require expert review and testimony of a nurse (RN or LPN, whichever applies to your claim).

http://www.hhs.gov/dab/decisions/cr922.html
This document contains the standards of care required by Medicaid and Medicare for the management of PEG tubes in Nursing Homes. The article deals primarily with new PEG tubes, but the standards listed are appropriate for PEG tubes that are not "new". The article describes the same physical damages as were suffered by the OP's brother.

For those who wish to skip the article: after calling the physician and talking with the PA who directed the RN to replace the PEG tube and in a later conversation added "or send the patient to the ER" to the directions, one or more RNs replaced a PEG tube that was pulled out by the resident of the Nursing Home in the above-reference article. The patient's condition deteriorated, the patient was admitted to the hospital where it was discovered the feeding was going into the peritoneal cavity. The patient was septic and died. The Nursing Home was fined $10,000 and appealed. This article is the decision regarding the appeal. The actions of the PA, the RNs, and the Nursing Home were found to be below the acceptable standards of care and the $10,000 fine was upheld.

Best wishes,
EC

 

[baesmile1]

Thank you

I have printed this information previously and given it to the attorney, but will reprint and give to him again to be sure that he has it. Thank you SO much for your support and helpful information that you have offered.

In regards to the nurse, I believe that we will be able to use the nurse that works in the lawyer's office. She is an RN and works there as well as has her own business with a partner that provides care for those needing it in their home. I will be sure to follow up with the lawyer though to make sure that is taken care of. I am so hoping things will start moving a little faster now, at least just to know their side of it and feel like things are happening even if it does take some time to get through to completion.

My understanding of the doctor that is meeting with the lawyer this Thursday is that VA requires an expert review from the field to state that yes in fact this is a legitimate malpractice case before serving the case. The lawyer indicated that we would use him as our expert witness, but I guess in some ways I was assuming that this was who we needed in court, I better make sure we have the nurse too.

Hopefully I will have some more updates to post soon. My biggest concern here is that someone own up to their mistakes, take accountability for the pain and suffering that led to my brothers death, and make it public information that mistakes that have resulted in death have occurred in this facility. To date, they still show a near perfect record, just as they did when I researched to place my brother there.

Thanks again! Any additional advice is welcomed - you all have been wonderful! I appreciate your dedication to the board, and hope that some day I will be able to offer support to others as well.