I was working as a Certified Legal Nurse Consultant for a year when I received what came to be one of my most memorable CLNC cases. I began reviewing the records and discovered something wasn’t matching up. The documentation was perfect. In fact, it was too perfect – yet the patient’s condition continued to deteriorate.
The diagnosis didn’t reflect the documentation and I became suspicious. Shortly after, I realized I had encountered my first fraudulent charting case. I’ll never forget the moment – I ran out of my home office and into my living room to tell my husband. I was so proud to uncover the hidden facts and identify tampering. I took pride in knowing I helped to make things right.
This case was about a patient who developed an extensive pressure wound during admission to a nursing facility. The staff at the nursing facility failed to assess, diagnose and treat the wound in a timely manner. The wound deteriorated into a significant and infected stage 4 wound. The staff tampered with the records after the wound severely deteriorated to make it appear as if treatment was provided during the entire admission. Some of the major deviations from the standards of care included:
- Failure to properly assess the patient’s risk for skin breakdown.
- Failure to formulate a care plan to address skin concerns.
- Failure to implement preventative treatment for a patient with a high-risk for skin breakdown.
- Failure to provide daily assessments.
- Failure to implement proper wound treatment in a timely manner.
- Failure to maintain an accurate medical record. Documentation was inconsistent – often contradictory. The handwritten records didn’t correspond with the Electronic Medical Record (EMR). The staff documented medical treatment after the patient was transferred out of the facility. There were multiple days with missing nursing notes.
I was the consulting expert on this case. I reviewed the medical records, wrote a brief report and chronological timeline, drafted potential deposition questions and provided a list of requests for production. According to my attorney-client, as soon as the defense heard “tampering” they immediately settled the case. “The case just settled and your findings are a huge part of the success. Your superb work product led to this win. Keep up the great work!”
I feel this case was a pivotal point for my legal nurse consulting business. Not only did I gain confidence in myself and my abilities as a Certified Legal Nurse Consultant, but my attorney-client gained trust in me and provided me with more consistent legal nurse consultant jobs than ever before. My CLNC business has continued to thrive and I have a consistent flow of work coming in and each year my revenues increase.
This case taught me to be patient and to have confidence in myself. It taught me to continue to trust my instincts and apply my critical thinking skills and nursing judgment to every case. It taught me to take the necessary time on each case and to dig a little deeper when the clinical symptoms or diagnoses don’t match up with the documentation. If I hadn’t, I could have easily missed the tampering. Medical records are rarely black and white. It’s our job as Certified Legal Nurse Consultants to investigate by taking an indepth look to see what might be missing or altered, and to determine whether everything was done according to the recognized standards of care. I’ve consulted on a handful of tampering cases since this one, and I have to say, they are definitely my favorite.
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Michelle Neal, RN, BSN, CLNC is the owner and president of Neal Legal Nurse Consultants, LLC in Vero Beach, Florida. Her clinical nursing expertise includes emergency medicine and she consults on medical malpractice, personal injury and long term care cases.
P.S. Comment to congratulate Michelle and to share your most memorable CLNC case.