Case analysis: Decision – making
Jill is a physical therapist and Director of Rehabilitation Services in a Skilled Nursing Facility (SNF). Mary is a 75-year-old female who was admitted to the facility for continuation of rehabilitation secondary to a total hip replacement. After treating Mary one Sunday afternoon, Jill wheeled Mary back to her room. She documented the treatment performed, and then went to another facility to treat a few more patients.
The following day, Jill received a call from Edith, the Director of Nursing Services at the SNF. Edith stated that a few minutes after Jill left, Mary evidently tried to get up from her wheelchair to turn down the volume on her television and fell, hitting her head on the floor. When asked why she tried to get up on her own despite instructions not to do so, Mary stated that Jill did not put her call light within reach and that there was no one around to call. Edith relayed that Mary’s condition deteriorated over a 12-hour period and was subsequently sent out to the acute care hospital (immediately after the incident, Mary’s physician was called and he ordered them to keep Mary in the facility for observation). Mary suffered an intracranial hemorrhage and died early the following day.
That same day, Jill, Edith and Betty (the SNF administrator) met to review Mary’s chart. When asked if she made sure Mary had her call light, Jill stated that she was not sure if she did. Jill admitted to being preoccupied that day because of her heavy caseload and other personal problems. However, Jill stated that she always placed the call light within reach of her patients in the past. Edith and Betty then asked Jill to revise the PT note that she did the day before to reflect that she had given Mary the call light. Edith, who was also the charge nurse on the day of the incident, already reconstructed her chart entries accordingly. Betty was afraid of a big lawsuit coming from Mary’s family, so she ordered everyone involved in Mary’s care to strengthen their documentation to reflect that the facility was not responsible for her injury and consequent death.
Jill was pressured by Betty to change her documentation. Implying that she may be terminated if she did not agree to make the revisions. Betty wanted Jill to completely revise the whole note. Consequently, Mary’s family sued the SNF for negligence.
Question: There exist two issues in this case that require legal analysis. What are those two issues and provide discussion of the issues.
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