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Jenkins Case Analysis 

Jenkins Versus Payne Case Analysis

Read the Jenkins Versus Payne Case Summary that follows and the designated Rules below.  When responding to the questions, identify the applicable rule by using number/s and or letter/s of the statute/regulation.  For example: Rule 224.1 (2) (A). Do not include the text of the rule in your response.

Instructions

  1.  Identify those standards of practice in Rule 11 (Links to an external site.) (Texas Nursing Practice Act, Amended 2013) that are applicable to the Nurse Practitioner in this court case. Be sure to consider the standards of practice that apply to all nurses, registered nurses, or advanced practice nurses as they are all applicable to a nurse practitioner.

  2. Identify the conduct statement(s) in Rule 12 (Links to an external site.) (Texas Nursing Practice Act, Amended 2013 ) and the NP’s behavior that violated the standard of practice.

  3. Identify two (2) ethical principles with rationale for each that were not followed by the NP.

Case - Jenkins v. Payne 465 S.E. 2d 795 (1996)

FACTS: In January 199l, the patient, Veronica Payne, was initially seen by a nurse practitioner, who was supervised by a family practice physician, for complaints of a discharge and scabbing of her left breast nipple. The NP ordered a mammogram, which was reported as negative. The NP prescribed antibiotics for the problem.

Six months later the patient returned to see the NP with complaints of continuing pain and discharge from her left breast nipple. The NP referred the patient to a dermatologist for treatment of the persistent left breast irritation.  The NP did not document the fact that she had any discussions with the patient regarding the possibility of breast cancer or the need for a biopsy.

The patient was seen by a gynecologist on October 21, 1991 and on November 8, 1991 for her breast complaints. The gynecologist prescribed antibiotics and a topical steroid cream and diagnosed her as having eczema. The gynecologist documented a past history that the patient had an inflamed and bleeding left nipple for 1 ½ years. Ms. Payne maintained that the gynecologist reassured her that she did not have breast cancer. During 1992, the patient was seen several times by the NP and the gynecologist. Neither of these health care providers documented that they had reexamined the patient’s breasts or inquired whether the problem still persisted.

On September 23, 1992 the  NP performed a breast exam on Ms. Payne and discovered multiple masses in the patient’s left breast. In December 1992, Ms. Payne was diagnosed with Paget’s disease in the terminal stage with lymph node metastasis. Ms. Payne died in April 1994.

Prior to her death, Ms. Payne filed a medical malpractice claim against the NP and 5 physicians, alleging the failure to diagnose and treat her breast cancer and for the misdiagnosis.

TRIAL COURT: Evidence was presented by experts that Paget’s disease is a cancer of the nipple and milk ducts and classic symptoms of this disease are discharge, skin lesions, nipple inflammation, and irritation. In the early stages, the cancer is noninvasive, and there is a 10-year survival probability of nearly 90% had her cancer been diagnosed when it was noninvasive. The plaintiff’s expert surgical oncologist testified that Ms. Payne’s cancer became invasive 3 to 6 months prior to the December 1992 diagnosis.

            The NP’s supervising physician testified that he was responsible for the care of all patients treated by the NP and held daily discussions with the NP regarding her treatment of any seriously ill patients. He acknowledged that he knew a biopsy was necessary in order to differentiate Paget’s disease from a benign problem. he testified that he was aware of Ms. Payne’s breast problem and in January 1992, he recognized that there was a chance Ms. Payne had Paget’s disease but did not discuss this possibility with the NP or the patient.

            Expert testimony was given at the trial that the supervising physician and the NP breached the standard of care by failing to recognize the symptoms of breast cancer, by failing to refer the patient for a biopsy, and for misdiagnosing the problem as an infection.

            Both the plaintiff and defense presented expert nurse practitioners to testify on the standard of care.  While the action was pending, Ms. Payne died as a result of her disease, and the claim was amended to allege a cause of action for wrongful death.

TRIAL COURT DECISION: The jury awarded $1.1 million verdict against the defendants. The gynecologist settled his claim for $450,000 prior to trial. An appeal was filed by the defendants alleging that the gynecologist was the sole proximate cause of Ms. Payne’s death.

APPEAL COURT DECISION: The appellate court affirmed  trial court’s jury verdict.

ANALYSIS: The NP was held liable for misdiagnosing Ms. Payne’s condition and failing to recognize the symptoms of breast cancer. The NP also breached the standard of care for failing to follow up with the patient as to whether the treatment she had prescribed was effective. The lack of documentation about any discussion regarding a biopsy and the possibility of breast cancer also was significant.

            The supervising physician, although not directly involved in seeing the patient, through his discussions with the NP suspected that Ms. Payne may have had Paget’s disease but did not tell the NP or the patient, nor did he refer her for a biopsy.

            Tragic events can occur when the NP fails to timely diagnose and follow up on a patient’s condition.

 

Source: Brent, N.J. (2001). Nurses and the law: A guide to principles and applications. 2nd ed. Philadelphia: W.B. Saunders Company. pp. 484-86. (2011do)

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 Jenkins Case Analysis

Health professionals often face ethical challenges in the treatment and follow-up of patients. It is evident in Jenkins’s case analysis where the nurse practitioner is liable for the misdiagnosis and failure to recognize breast cancer. The NP also fails to follow up on the patient about the prescribed medication efficacy. Although the supervising physician commented on the need for a breast biopsy to the patient, there is no documentation to support the assertions. The supervising physician also fails in his role because he does not refer the patient or tell the NP about the need for a biopsy irrespective of his suspicion of Paget's disease.

Violation of the Standards of Care

The NP violates rules 217.11 (D) (N) (M) and (Q) on standards of nursing practice. Under rule 217.12 (A) (B), the NP fails in the role of accurate reporting and documentation. Although there is a referral to the dermatologist, there is no documentation on the discussion held about the possibility of breast cancer or the need for a biopsy. Failure to document patient care matters is a risk factor for poor outcomes, liability issues, and a violation of the minimum acceptable standards of NP practice. The NP also portrays unprofessional conduct under rule 217.12 (E). She takes up the role of managing Payne with a potentially serious illness without the involvement of her supervising physician. Doing so increased the patient's risk for unsafe and ineffective care which eventually resulted to her death.

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The NP violates rule 217.12 (4) by failing to clarify the plan of care despite reasons to believe that it could be inaccurate. After Veronica Payne returns to the clinic after six months, the NP refers her to a dermatologist due to continued pain and discharge from the left nipple. However, there is a discussion about the possibility of breast cancer before the referral. It shows that the NP was in doubt about the patient's diagnosis but failed to clarify the concerns through appropriate referrals and diagnostic tests. Instead, the NP refers Payne to a dermatologist and not for breast cancer screening to rule out or confirm her cancer suspicions. By recognizing Paget’s in the early stages, the NP would have improved the patient’s life expectancy by preventing progressive invasion of the cancerous cells. In contrast, she violated the standards of nursing practice and endangered the life of the patient.

Violation of the Ethical Principles of Care

The NP's breach the ethical principle of beneficence intended to provide a better outcome for a patient’s condition. In 1992, the NP sees the patient several times but fails to re-examine the breasts or enquire about the persistence of the breast problem. It indicates the lack of moral conviction to benefit the patient towards better outcomes. The case also portrays a violation of the principle of non-maleficence. Through an act of omission, the NP fails to follow on her suspicions of cancer by referring the patient for a biopsy. It is also evident where the NP fails to follow up on the client to determine the efficacy of the drugs on the patient's condition. The two situations portray ethical misconduct under the principles of beneficence and non-maleficence.

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