The elderly patient resided in a nursing home for almost a year before she died at the hospital.

The elderly patient resided in a nursing home for almost a year before she died at the hospital. She had been hospital-ized for six days, with admitting diagnoses of gram nega-tive septicemia, gram negative sepsis, and acute myeloid leukemia. Also, discovered on admission to the hospital was a necrotic Stage III pressure ulcer on her coccyx, which was nowhere documented in the clinical records from the nursing home. A review of the nursing progress notes was 

silent regarding any specialized mattress or other comfort devices used for this patient. The family sued on behalf of the patient, alleging that the patient’s demise from leukemia was linked to the negligence of the care that the patient had received in the nursing facility. The defense lawyer for the facil-ity denied any negligence in the cause of the patient’s death.  

1. Did the lack of documentation affect the ultimate out-come of this case? 

2. Was there negligence on the part of the nursing staff in the care of this patient? 

3. Was negligence in the care of this patient the ultimate cause of her demise? . 

3. After learning the purposes and guidelines for documen-tation, how might one design a better chart? 

4. What safeguards can be used to ensure confidentiality when sending medical information by fax or by e-mail? 4. What standards for documentation did the patient’s nurse breach? 5. How would you dec