Issues involving a consultant's obligation to nursing home residents.

Ms. Mary Walen, a widow and 75 years of age, was living at home independently when one Friday afternoon she slipped on a throw rug in her living room and immediately felt severe pain in her left ankle. She was able to call 911 and was transported to the Emergency Department of Memorial Hospital. Examination revealed she had fractured her left ankle. Her past medical history was significant only for osteoporosis, for which she was on calcium, vitamin D, and estrogen, and mild venous insufficiency. No laboratory tests were drawn, and Ms. Walen’s physical and mental status exams were felt to be within normal limits. The Emergency Department surgeon casted her left ankle and arranged for a staff podiatrist, Dr. White, to see her for follow-up the next day. Dr. White had privileges at Memorial Hospital to care for fractures of the ankle. Because Ms. Walen lived on the second floor of her home, it was decided to admit her to Brentwood Nursing and Rehabilitation Center for 1 week until she could safely ambulate. Hasty arrangements were made by the Emergency Department for admission on Friday evening. Dr. White subsequently spoke with the Emergency Department physician by telephone and was told that Ms. Walen needed to be seen the next day, and this was written on the transfer order sheet to Brentwood. Tylenol was ordered for pain along with complete bedrest. The following morning when Dr. White arrived to examine Ms. Walen at the nursing facility, Dr. White was told by the staff nurse on duty that Ms. Walen’s insurance was issued by a private HMO and that Dr. White was not on the authorized podiatry panel. The staff nurse said that the HMO would have to send out their own podiatrist for the follow-up visit. The nursing supervisor and administrator were not called. According to Dr. White’s office records, she then walked down to Ms. Walen’s room and explained what she had been told and left her a business card. Later that evening Ms. Walen began to complain of severe left calf pain. No podiatrist from the HMO ever arrived, and the assigned attending physician of record at the nursing home, Dr. Stevens, was not scheduled to see Ms. Walen until Monday. The following morning the nursing staff found Ms. Walen acutely short of breath, cyanotic, and tachycardic at a rate of 125 beats per minute. Staff immediately called 911, but Ms. Walen went into cardiac arrest shortly thereafter. Paramedics arrived at the nursing home approximately 5 minutes later but were unable to resuscitate her. An autopsy was subsequently authorized, and a massive pulmonary embolus was found with a large thrombus noted in her left calf. Cause of death was listed as cardiopulmonary arrest secondary to pulmonary embolus due to an acute venous thrombus of the left calf. The family subsequently filed a lawsuit against the nursing home for failing to provide adequate and appropriate medical follow-up.