Nurses Service Organization
Nurse Practitioner Case Study: Failure to Screen and Test for Lead Poisoning, Leading to a Delay in Diagnosis
“Medical malpractice claims may be asserted against any healthcare provider, including nurse practitioners. This medical malpractice case study with risk management strategies, presented by NSO and CNA, involves a Certified Pediatric Nurse Practitioner-Primary Care (CPNP-PC) working in a pediatric practice.
Summary
A pediatric clinic in a large urban city had been caring for a patient since she was two days old. The mother reported no problems during the pregnancy or birth of the patient. The patient lived with her parents and three older siblings in a two-story house a few minutes from the clinic. The three older siblings also were patients at the clinic and, apart from the occasional ear infection or viral illness, were healthy and meeting all of their developmental milestones. Over the course of two years, the patient was treated by several of the providers in the practice for both well and sick visits.
The patient had met all of her developmental milestones for the first year of her life. At the 12-month wellness visit, the patient was seen by one of the three CPNP-PC (co-defendant) working in the clinic. The mother testified that during this visit she asked the CPNP-PC if any blood work needed to be performed, as her other children had blood work drawn at their 12-month well child visit. The CPNP-PC reported that she discussed milestones and vaccines with the mother. However, there was no record in the patient’s healthcare information record of this discussion or of the query regarding lab work. The only note related to lab work was ‘deferred’, written by the provider next to the topic of lead screening on the form, but no explanation as to the reason for this notation.
Three months later, the patient presented to the office with symptoms of a cold and a runny nose. This was the first time the insured CPNP-PC (defendant) saw the patient. The insured CPNP-PC testified that she did not conduct a risk assessment for any needed wellness lab work or vaccinations because this was a ‘focused sick visit’. She diagnosed and treated the patient for an upper respiratory infection.
The insured CPNP-PC saw the patient again for her 15-month well visit. The intake nurse documented that the mother has ‘new concerns because she doesn’t feel like the child is talking much.’ The intake nurse checked the box indicating the patient was meeting the 15-month milestone of saying "single words," but added "sometimes" beside the check box. The mother reported that she did not believe that her daughter was talking appropriately for a 15-month-old. The mother stated the child was not stringing words together and frequently pointed to items, rather than verbalizing.
The mother contended that the CPNP-PC responded by stating that a response of single words was normal for a 15-month-old. The mother testified that she verbalized a concern with the issue of lead exposure and a lack of blood work during the visit. She stated that she was familiar with such testing due to her other children having been tested, as well as based upon her prior employment as a medical assistant at a pediatric practice. The CPNP-PC asked if they ‘lived in an old house,’ to which the mother responded that she did not know the year that house was built, as it was owned by her parents. The mother testified that the CPNP-PC stated, ‘She's probably fine.’
The healthcare information record did not reflect any reference to an inquiry regarding lead exposure or lead testing. On the section of the healthcare information record labeled ‘Lead Test,’ the CPNP-PC wrote that the patient was ‘Ø at high risk,’ which she testified as meaning that she had reviewed the risk factors with the parent.”