Failure to properly manage patient’s central venous catheter

Presentation

A 63-year-old woman was hospitalized for treatment of renal and urological issues. Two years earlier, she had been diagnosed with renal cell carcinoma. The patient’s history included diabetes, obesity, and breast and colon cancer. The patient lived in a small, rural community.

The patient had seen multiple physicians during her hospitalization, including her long-time physician, Family Physician A. She was discharged to a local rehab center with diagnoses of radiation cystitis, acute renal failure, right renal mass, urinary tract infection, E. coli infection, pneumonia, and splenomegaly. She was to receive IV antibiotics at the rehab center.

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Physician action

During a visit on day 32 of her rehab stay, Family Physician A documented that the patient had signs of infection in the central venous catheter (CVC). His handwritten note said “septic-unlikely pt apprs well.” A typed assessment stated:
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“1. Groin area fungal infection 2. Right port-a-cath with hyperemic irritation part of the chest rash or infection secondary to patient already having a lot of skin reaction will treat with only [fluconazole]. 3. Skin reaction. 4. Septic? (Consider this diagnosis in need to transfer to [city], discussed with [son] to help with getting patient to a urologist, patient medical problems could be addressed and patient could get surgery done since it keeps getting postponed, [son] prefers [hospital name] but agrees and other hospital would be ok, not septic.”
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Family Physician A’s plan was to treat the patient with diphenhydramine, cetirizine, and fluconazole. “Refer to surgery for removal of port-a-cath. Will look for another urologist. Discussed with [son] about accepting another urologist for the renal cancer . . . to hospitalize patient in [city] so that the surgery can occur as soon as possible, if still a candidate.”
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Two days passed and rehab center staff advised Family Physician A that the patient had a fever. He told staff to take the patient to a local ED if the fever did not respond to acetaminophen. Following a phone call from the patient’s son reporting that the patient had a hard, painful area on her lower right abdomen, Family Physician A instructed rehab center staff to take the patient to a local ED.
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The patient was admitted to the hospital that day with “acute septic shock likely secondary to urinary tract infection for Gram negatives; hypotension; acute kidney injury superimposed on chronic kidney disease stage 4 or 5; allergic reaction, Stevens Johnson like type; and renal mass, which is likely cancer.”
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The next day, the patient was transferred to an urban medical center. Her prognosis was poor, and she died two days after the transfer.

Allegations

A lawsuit was filed against Family Physician A. The allegations were failure to discontinue the CVC when it was no longer needed and failure to order cultures and antibiotics if he suspected a CVC infection.

Legal implications

Although physicians who reviewed this case for the defense stated that Family Physician A met the standard of care, there was concern that he did not order cultures or start antibiotics though he noted a possible infection. Reviewers also stated that the order to remove the CVC should have been designated as “STAT.”

Regarding causation, one physician reviewer stated that the patient likely had an acute skin condition such as Stevens-Johnson Syndrome or toxic epidermal necrolysis at the CVC site. Further, if the CVC site was infected and that infection became so severe that it caused the patient’s death, the site would likely have displayed gross evidence of infection (swelling, redness, warmth, tenderness, etc.). According to this physician, the sepsis, septic shock, and multi-system organ failure that caused the patient’s death were “entirely independent” of the CVC.

Documentation was a weakness in this case. He testified that though he did not think there was a CVC infection, he documented that there was so the patient could be transferred to an urban hospital and undergo surgery for the renal mass. He stated he was trying to help the family. Yet it was later discovered that the notes about the expedited transfer to an urban hospital were added to the medical record six days after the patient’s death.

Disposition

This case was settled on behalf of Family Physician A.

Risk management considerations

Physicians who practice in rural areas face unique circumstances that can increase liability risks.

• Limited access to specialists often means primary care physicians manage complex conditions that would typically involve specialty consultation in urban areas.
• Greater distances to specialized care centers can delay transfers when urgent issues arise.
• Fewer resources for diagnostic testing can lead to delayed diagnoses.
• Staffing shortages may cause less frequent patient monitoring.
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For physicians practicing in rural communities, developing strong referral networks and clear transfer protocols is essential. Telemedicine can be a valuable tool to bridge some of these gaps, allowing for remote consultation while keeping patients in their communities when appropriate.
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Proactive risk assessment — identifying which patients might need more urgent intervention or transfer — can help mitigate these care challenges.
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Documentation becomes even more critical when treating patients in these settings, as care coordination between physicians and facilities requires clear communication. However, inaccurate documentation was a factor in this case. Family Physician A’s notes were inconsistent with his testimony, and he admitted that he documented an infection that he believed did not exist to facilitate a transfer. Furthermore, the notes regarding the expedited transfer were added to the medical record days after the patient’s death.
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To maintain the accuracy and integrity of medical records, document patient assessments factually and contemporaneously. Avoid falsifying or exaggerating conditions to achieve secondary goals like transfers. Accurate medical information must be available to all members of the care team and lessens the chance that the facts of the case can be contested.
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Avoid making late additions to the medical record after an unexpected outcome.  An addendum or late entry in a medical record may be allowed if done in a timely manner and clearly identified. Include the date and time of the addendum, the date and time of the actual encounter, reason for the late entry, the added information, and signature of the author. After-the-fact entries may be viewed as record alterations and may ultimately compromise the defense.