Joseph Brant Memorial Hospital v. Koziol

Kolesar should have been roused at 12 p.m. midnight and made to deep breath and cough every 15 minutes at least during the night so that fluids would not collect in his throat and lungs.

[This evidence related to the note timed at 10 p.m. that Kolesar had not voided and had been twice sedated.]

[Page 497]

Physiotherapy in the form of movement of the arms should have been given at the same time.

The large quantity of fluids ought not to have been given to him orally, and on learning of the fluids which had been given prior to midnight together with the constant flow of intravenous fluids, the nurses should have realized the patient’s body systems were overloaded with fluid. He should have been watched carefully because of the danger of regurgitation, his stomach palpated and catheterized.

Blood pressure, respiration, pulse and temperature should have been taken and recorded at regular intervals.

The failure to chart and make nurses notes between 10 p.m. on the 30th December and 5 a.m. on the 31st December is a definite breach of basic record keeping in the management of the case. The hospital is an accredited hospital under the Canadian Council on Hospital Accreditation. I do not think I can better emphasize the need of prompt and accurate record keeping than by quoting from Exhibit 31 at p. 69:

On a ward with a great many patients the medical record becomes the common source of information and direction for patient care. If kept properly it indicates on a regular basis the changes in the patient’s condition and alerts staff to developing dangers. And it is perhaps trite to say that if the hospital enforced regular entries during each nursing shift, a nurse could not make the entry until she had first performed the service required of her. In Kolesar’s case the absence of entries permits of the inference that nothing was charted because nothing was done.

A post-operative patient is usually very disturbed, sleeps only from hour to hour. If Kolesar was pale, slept peacefully all night, that in itself was a danger signal. He should have been aroused hourly, compelled to deep breath and cough, and if fluid in the throat or tubes was present a suction device should have been brought in.

Merely looking at the patient, even if regularly, is not sufficient.