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Don’t destroy those documents!

By Heather Brown
November 21, 2014

My coach often told us, “The best offense is a good defense!” It seems kind of strange to think that this saying can be carried to adult residential care communities; however, it is one of the most important things an adult residential care can do to stay out of a court room. The following claim could have had a completely different result had documentation been preserved regarding the resident. A Dementia plaintiff had cardiac catheterization, and was re-admitted to the facility on November 12, 2004. The resident was found unresponsive on Nov 22, 2004, and he died the next day, due to a cerebral hemorrhage, due to a Coumadin overdose. The facility had no authority to render medical treatment or services, outside the very limited area of complying with the timing and administration of medications per doctor’s orders. There is no indication that the insured administered the wrong dosage. The critical factual issue for the facility is the determination of where the Nurse (employed by co-defendant) obtained her information about the Coumadin dosage and did she have a right to rely on that source. Overriding that issue is the co-defendant Dr. X’s failure to meet the standard of care when he prescribed Coumadin on Nov 16, 2004. The facility’s exposure is derived from the failure of the staff to communicate the proper dosage information. The insured says that they did not know about the Coumadin until Nov 16, 2004. The Nurse testified that the facility personnel told her that the resident was on 5 mgs daily. This confusion could lead a jury to believe that the Doctor’s confusion about the Coumadin dosage came from the Nurse, who got it from the Facility. Originally the claim appeared moderate with expenses to be around $27,000, and indemnity estimated at $50,000. Litigation involving multiple defendants is always protracted and very expensive. However, on October 27th, 2009, the claim took a turn for the worse…

Here’s a big lesson for the week:  Don’t destroy your documentation.  It is the only thing that can defend if a lawsuit is ever filed.  Good documentation will help keep the facts straight.  I’ll see you next week with the ending to this story and more tips on better documentation.

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