Med Law Advisory Partners, under the leadership of Alicia Davis, RN, LNCC, has announced the unification of former ALN Consulting services under the Med Law Advisory Partners name.

“Our goal is to assist our clients in the most efficient and expert way possible,” says Alicia Davis, Founder & CEO, “Combining our services under the Med Law Advisory Partners name is a way to best serve our partners.”

The ALN Consulting Story

In 2002, Davis founded ALN Consulting after a fifteen-year nursing career. Coming from a background in nursing, Davis’ unique expertise allowed her to build ALN Consulting as a revered national provider of medical-legal consulting services specializing in the areas of medical malpractice and long-term care litigation.

In 2019, Davis started a new venture to further work being done to combat the opioid epidemic in the United States. “I started this venture after I was involved in an opioid prescribing investigation that broadened my perspective on how patients with chronic pain were being managed,” says Davis.

Med Law Advisory Partners began as ALN Consulting’s opioid prescribing audit service to assist healthcare providers in identifying current opioid prescribing practices and developing prescribing protocols that will help improve care and mitigate risk for the organization. To best serve clients and partners, Med Law Advisory Partners is now combining all services under the Med Law name.

About Med Law Advisory Partners

The Med Law team includes experienced nurse consultants and dedicated administrative staff, who support clients nationwide. As leading national medical-legal consultants, our skilled consultants work directly with legal teams to provide clinical expertise and ensure positive outcomes in medical-legal matters.

With nearly 20 years of experience in the medical-legal field, we are proud to provide consulting services in healthcare and regulatory law. We have worked with healthcare systems, insurers, facility operators and government entities to help assess risk and manage healthcare claims from both the plaintiff and defense perspective. Our mission is to improve healthcare by offering resources and expertise in the areas of safe opioid prescribing, medical malpractice, and long-term care litigation.

Founded by Alicia Davis, RN, LNCC, Med Law Advisory Partners (and former ALN Consulting) provides resources and expertise in the areas of safe opioid prescribing, medical malpractice and post-acute care litigation, including COVID-19 claims. Alicia and her team have worked with government entities, healthcare systems, insurers and senior-living operators for nearly 20 years, helping mitigate risk and manage medical-legal and healthcare fraud claims.

In order to evaluate a medical malpractice case, there needs to be a solid understanding of the four elements of negligence. The term “medical malpractice” encompasses negligence on the part of any healthcare professional to a patient. In addition to medical malpractice by physicians, professional negligence also includes nursing malpractice, dental malpractice, pharmacy and chiropractic malpractice.

Professional negligence claims fall under the category of civil law. Civil law encompasses disputes between individuals or organizations in which compensation is sought for harm resulting from negligent conduct. This is opposed to criminal law, which regulates social behavior that endangers the health, safety, and welfare of others and punishes the defendant for violating these laws.

To prevail in a professional negligence claim, there are four elements of the claim that must be proven. These four elements are duty, breach of duty, damages and causation.

As the initiator of the lawsuit, the plaintiff has the burden of proving all four elements by a preponderance of the evidence. Note that this standard is less strict than in criminal cases, where the claims must be proven beyond a reasonable doubt. In civil cases, the standard of proof is “more likely than not” or “greater than a 50% chance” or “to a reasonable degree of probability.”

While the plaintiff must prove all four elements to prevail, the defense only has to raise enough doubt about any one of the four elements to succeed. If the jury or other finder of fact believes that the plaintiff has not met the burden of proof for any one of the four elements, they must find for the defense.

Tort law falls under the umbrella of civil law. A tort is a wrongful act, whether intentional or accidental, from which injury occurs to another. Torts include all negligence cases as well as intentional wrongs, which result in harm. Medical negligence is one example of tort law. Others include premises liability, motor vehicle accidents, product liability and environmental pollution.

Damages

Damages are any loss, detriment or injury that directly results from a breach in the standard of care. The term “damages” also refers to the monetary compensation awarded to the plaintiff for proven or established injuries. There are three categories of damages, and money can be awarded to the plaintiff for damages in any of these categories. The three types of damages are economic, non-economic, and punitive.

Economic damages are also referred to as “special damages,” and they are the out-of-pocket expenses incurred by the plaintiff that are related to the claims in the case.

For example, economic damages may include medical expenses such as hospitalization, surgery, doctors’ appointments, physical therapy, other treatment, co-pays, assistive devices, and other equipment.

Economic damages may include mileage, toll road fees, hotel expenses, etc. when traveling to see a specialist. Economic damages may include household help or, in the case of wrongful death, funeral expenses. Lost wages and loss of earning capacity are also examples of economic damages.

Non-economic damages are also referred to as “general damages,” and these are the intangible injuries suffered by the plaintiff. Examples of non-economic damages include pain and suffering, mental anguish, embarrassment, disfigurement, functional limitations, and loss of enjoyment of life. Non-economic damages can also include loss of chance, which is a reduction in the plaintiff’s “chance,” or opportunity, for a more favorable outcome due to the negligence of the defendant.

Non-economic damages may also include loss of consortium. This is a damage claimed by the plaintiff’s significant other for deprivation of the benefits of a family relationship, including intimacy, affection, companionship, and sexual relations.

Punitive damages, also known as exemplary damages, are monetary compensation exceeding general and special damages. They are typically awarded when the defendant’s actions are found to be egregious or grossly negligent.

Gross negligence is behavior that falls very far below the standard of care; it is blatant and voluntary carelessness, indifference, and disregard for the safety or lives of others. Punitive damages exceed the amount intended to compensate the plaintiff for the harm suffered. These damages can be difficult to prove in professional negligence cases and may be capped in many jurisdictions. Punitive damages are intended to punish the defendant, set an example, and deter future behavior considered “outrageous.” Most jurisdictions will often not even consider such a motion until all the facts have been set forth and even if allowed, caps on the amount awarded are often in place.

Causation

Causation is the connection between medical carelessness, breach of duty, and patient injury or damages.

To understand causation the LNC must think carefully about the following questions: Did the negligence cause the injury or damage? Could it have been caused by something or anything else? Did the negligence cause all or only part of the plaintiff’s injury? If only part, which part?   Is there any reason why the result would or could have been the same absent the negligence? In death cases, would the plaintiff have died of his disease absent any negligence? If so, what are the statistics on morbidity and mortality for that specific condition?

During the course of a case investigation, as new facts are discovered the LNC should rethink causation and how the new information or new defense argument fits the existing causation theory.  Deep understanding of the four elements of negligence is very important as ALN updates cases with newly obtained information. It is critical to have a legal nurse on your team who understands how to spot inaccuracies in medical records that can affect case outcomes, and can determine if the case meets the four elements, which constitute negligence in a Medical Malpractice case. Contact us today to learn more how we can help.

ALN has participated in large scale analysis of cases of worthless care brought forth by the Department of Justice / Office of the Inspector General. Review of these case are approached differently from those of typical litigation. In reviewing cases of allegations of worthless care, ALN must take a broader approach, looking at the overall care provided, rather than looking at specific events, breaches from standard of care, or level of harm.

In this investigation, the ALN Reviewers scoured the medical records to ascertain the actual care provided, producing reports and demonstrative evidence to prove the provision of care. The reports proved, although care may not have been perfect, it was not worthless. One such case included a resident of a long-term care facility. We will call the resident Ms. Jones. DOJ/OIG lodged allegations of worthless care in regards to Ms. Jones related to poor hygiene, medication errors, and poor nutrition.

The allegation related to poor hygiene indicated Ms. Jones did not receive showers during her extended residency. In review, records revealed Ms. Jones’ need for assistance with ADLs was assessed and an appropriate care plan was developed to address the issue. ADL Sheets were presented as demonstrative evidence of daily provision of personal care and bathing. The records showed bathing was always in the form of bed baths, and the resident did not receive showers as she should have; however, the fact remained that bathing was received and personal hygiene maintained. Although this evidence was sufficient to prove the staff provided appropriate care and hygiene, the reviewer went a step further to prove proper hygiene. OT records were produced that showed assistance with provision of ADLs and provision of therapy to improve self-performance of ADLs. Psychiatric Consultation Notes and MD Progress Notes were also produced to show documentation of the resident being well-groomed. With the myriad of documentation from different sources, the reviewer was able to prove the care provided was not worthless, although no actual showers were received.

The allegation related to nutrition was completely proven false by the ALN Nurse Reviewer. The allegation cited failure to properly maintain a feeding tube resulting in altered nutrition. The OIG asserted the care plan indicated tube feeding was to be provided, but the TARs indicated it was not supplied. Upon review of the records, the ALN Reviewer presented evidence supporting staff routinely assessed Ms. Jones’ nutritional status and her feeding tube. A care plan was developed to address Ms. Jones’ nutritional status and feeding tube. Tube feedings were administered appropriately and speech therapy implemented to promote p.o. intake. Ms. Jones’ progressed to eating a p.o. diet and tube feeding was discontinued. Ms. Jones’ was subsequently able to have her feeding tube removed. Upon discontinuation of tube feeding, staff failed to update the care plan, therefore, the care plan continued to indicate provision of tube feeding, and the TARs revealed none was delivered. The reviewer admitted the nutritional care plan was not updated appropriately. Tube feeding was not being administered, as it was no longer ordered or warranted. Although failures in documentation existed, the resident’s nutritional and overall status improved showing the care provided was not worthless.

The DOJ/OIG also presented allegations related to medication errors, stating that medications were not always readily available, and thus omitted. The DOJ/OIG cited various medications over the course of the extended residency. The ALN Nurse Reviewer presented pages of MARs showing appropriate administration of 2700+ medication doses over the course of the extended residency. The ALN Nurse Reviewer could not refute the fact that 4 medications were omitted due to unavailability, but the big picture revealed a different story. Unfortunately, there was another issue to the medication errors, that of erroneous withholding of Coumadin. Review of the records indicated the MD stopped Coumadin pending a repeat PT/INR. Upon receipt of the subsequent PT/INR, the MD failed to write an order to resume the Coumadin, thus the medication was held for the subsequent 22 days. This error was to some degree the responsibility of the MD, who failed to write the order for resumption of the medication; however, nursing was responsible to follow-up on lab results and necessary medication adjustments, and thus the facility would also be responsible to some degree. Despite this erroneous withholding of medications, the overall medication error rate still did not exceed the 5% threshold for medication errors. All other medications were administered appropriately and her physical status improved, indicating the care provided was not worthless.

In the case of Ms. Jones, the ALN Nurse Reviewer investigated every allegation presented by the DOJ/OIG. Demonstrative evidence including power point presentations and reproduction of the actual resident’s chart were presented to prove the care provided by the facility. The ALN Nurse Reviewer took a holistic approach in presentation of evidence, not just presenting nursing documentation, but presenting documentation by therapists, psychiatric nurse consultants, and the physicians to prove the overall approach of care provided and the improved status of the resident. The records did show evidence of failures to appropriately update care plans, omissions of medication administration, and evidence of provision of bed baths instead of showers, but the overall records proved good and consistent care was provided. Although the care may not have been the most optimal on every occasion, the ALN Nurse Reviewer was able to prove the care provided resulted in improvement in the resident’s overall health status and quality of life, and clearly showed the care provided was not worthless.

When pursuing legal action for clients who have sustained a traumatic brain injury (TBI), attorneys must be able to assess the progression of damage and the prognosis for recovery.  One of the first steps is understanding the most common scoring system used to describe and record levels of consciousness in persons with an acute brain injury. Known as the Glasgow Coma Scale (GCS), the scale is a practical method of assessing impaired conscious level in persons injured from any cause, although it is most frequently used in cases of head injury.

First described in 1974 by neurosurgeons at the University of Glasgow, Scotland, the GCS was developed to provide a “universal” method of describing the responsiveness of a patient in simple, objective terms.  The verbiage has evolved since its introduction, but the scale itself has largely remained the same over time. It has become a critical tool for first responders, paramedics, and emergency room staff for measuring the degree of an acute brain injury.

The GCS measures functions involving eye opening, verbal response, and motor response. On a scale ranging between 3 and 15, a score below 8 indicates a severe injury, while 13 and above is considered a mild impairment. Clinicians use this scale to rate the best eye opening response, the best verbal response, and the best motor response an individual makes. The final GCS score is the sum of the number points in those categories. A modified version of the GCS is the Pediatric Glasgow Coma Scale (PGCS) which considers the eye, verbal, and motor response tests separately as well together.

This scoring system guides initial medical decisions and monitors changes in responsiveness. It is useful in monitoring chronic patients in intensive care. But even out of the ICU, the scale helps nurses spot important changes in a patient’s condition.  The timing and frequency of the assessment is individualized.  The role of the scale is to support and not replace clinical decision making.

Measuring Traumatic Brain Injury Response

The adult Glasgow Coma Scale measures functions as follows:

Eye Opening (E)

• 4 – Spontaneous
• 3 – In response to voice
• 2 – In response to pain
• 1 – None

Verbal Response (V)

• 5 – Normal conversation
• 4 – Disoriented conversation
• 3 – Incoherent words
• 2 – No words, only sounds
• 1 – None

Motor Response (M)

• 6 – Normal
• 5 – Localized to pain
• 4 – Withdraws to pain
• 3 – Decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bend and held on the chest)
• 2 – Decerebrate posture (an abnormal posture which can include rigidity, arms and legs held straight out, toes pointing downward, head and neck arched backwards)
• 1 – None

The Glasgow Coma Scale is not without its limitations. It only indicates a conscious level at the time the test is administered. By itself, it does not reveal how long someone has been unconscious or even, in the case of a high score, that he or she was unconscious at all at a previous point.  A dead patient can still be assigned a GCS of 3.

Some researchers are concerned with the GCS’s poor inter-rater reliability, or degree of agreement or consensus among those assessing a patient’s condition. It can also limited by the training a first responder or paramedic has in identifying and assessing brain injury.

A measurable level of brain injury can fluctuate significantly over minutes or hours – especially considering factors like shock, low blood oxygen, and the presence of drugs or alcohol in a patient’s system.  A GCS score can obviously improve by the time the patient reaches the emergency room. A very low score does not mean that a patient will never recover from his or her TBI. Likewise, a very high score does not mean that there is no brain injury present. The Glasgow Coma Scale complements, rather than substitutes, other neurological assessments.

When an accident involves a traumatic brain injury, time can be as valuable a resource as money for plaintiffs, defendants, and attorneys alike. Explicating all the fine points of consciousness and TBI takes plenty of both. A legal nurse consultant reviews client medical records and independently investigates the case. Your LNC can help your legal team determine a case’s merit and efficiently pinpoint medical issues and other factors that will affect how you proceed.

ALN was presented with a long term care case with allegations related to respiratory failure and death. At the time of the events in question, the plaintiff, Ms. Maggie White, was an 84-year-old female with a past medical history of coronary artery disease, chronic obstructive pulmonary disease, hypertension, anxiety, Alzheimer disease, chronic low back pain and lumbar disc degeneration. Ms. White was admitted to the defendant facility, a skilled nursing center, for rehabilitation after receiving epidural steroid injections for chronic low back pain.

Upon admission, care was implemented to include physical therapy and occupational therapy. During the course of residency, Ms. White developed a cough which progressed to chest congestion with decreased breath sounds. Prescribed treatment included cough suppressants, antibiotics, nebulizer treatments, and steroids. Ms. White’s chest x-ray was clear; her respiratory symptoms improved with treatment, but subsequently developed edema of the lower extremities bilaterally. Lasix was prescribed which resolved the extremity edema. Three days later, Ms. White was again found to have diminished breath sounds and labored respirations requiring a hospital admission. Admitting diagnoses included congestive heart failure (CHF) and cardiomegaly with respiratory failure. Ms. White was intubated and placed on ventilator support. Despite multiple consultations and treatments, Ms. White’s CHF worsened and she expired three days later.

Plaintiff’s counsel alleged that the defendant facility failed to properly assess Ms. White’s respiratory status and failed to provide timely treatment for shortness of breath, alleging the symptoms existed for days prior to transfer. Plaintiff’s counsel further alleged her respiratory failure and death were caused by the defendant facility’s negligence.

False Allegations Identified With Legal Nurse Review

Upon review of the facility records, ALN’s nurse reviewer was able to refute allegations of inappropriate assessment, as well as the existence of respiratory distress in the days prior to transfer. The investigation confirmed that the facility staff properly assessed, reported, and monitored Ms. White’s clinical status per facility protocol and long-term care guidelines. Although it was believed this information was enough to present an adequate defense, the ALN nurse reviewer dug deeper into the hospital records, striving to ensure the best possible defense was developed for the client.

Further investigation into Ms. White’s condition and circumstances surrounding her death revealed a myriad of possible contributing/causative factors. Ms. White had a recent diagnosis of possible heparin-induced thrombocytopenia (HIT). Research revealed that the most common complication of HIT is venous thromboembolism, including pulmonary embolism. Subsequent to Ms. White’s hospital transfer, the nurse reviewer’s investigation revealed that the physician consultants had conflicting opinions related to the cause of Ms. White’s respiratory deterioration. One theory the consultant considered was that Ms. White’s respiratory deterioration was possibly caused by a pulmonary embolism. In spite of this, Ms. White was never evaluated or treated for a pulmonary embolism or HIT. Although the resident was admitted with CHF, Ms. White was never adequately treated for the condition. Diuretics, a staple in CHF treatment, were discontinued – quite possibly contributing significantly to Ms. White’s declining heart function. Of further consideration was the fact that records indicated Ms. White had a probable new diagnosis of lymphocytic leukemia, which was never fully evaluated or treated. Investigation into Ms. White’s history revealed previous chest x-rays with evidence of pulmonary nodules which were never evaluated or treated. The cause of Ms. White’s death was listed as respiratory failure. As the ALN reviewer determined, the etiology of the resident’s respiratory failure was never confirmed and could have been the result of any number of conditions diagnosed after her rehabilitation stay at the defendant facility, which were not adequately evaluated or treated.

On initial review of the defendant facility records, the ALN reviewer was able to produce evidence showing the facility met the standard of care for evaluation and treatment of the respiratory symptoms Ms. White developed while a resident at the Defendant facility. The ALN reviewer’s in-depth investigation into Ms. White’s comorbid conditions and history revealed a myriad of possible sources for Ms. White’s respiratory failure and death – greatly expanding the client’s ability to argue against the facility’s liability and help mitigate possible damages.

In this case, the expertise of the ALN nurse reviewer was crucial in identifying possible contributing factors and raising questions regarding causation and mitigating factors – factors which would have gone unnoticed by a non-clinical professional. ALN Consulting’s team of nurse consultants are in a unique position to build the strongest, most manageable court case for their clients. We find the root issue by digging deeper.

Contact ALN Consulting to have your case reviewed by a team of expert legal nurse consultants who can identify inappropriate allegations.

ALN Consulting is a national provider of medical-legal consulting services, founded in 2002. Our expertise includes, yet is not limited to, medical malpractice, long-term care, product liability, class action/mass litigation, and toxic tort. Contact Us to put our legal nurse consulting experts on your case.