Physical Abuse, Accidental Trauma, or an Underlying Condition?
Studies have shown that one in ten children reported to have been abused and/or neglected. In 2022, California had a staggering number of over 300,000 referrals for child abuse and neglect. The largest age group affected were children under 1 years of age. These children are often immobile and non-verbal, which presents a challenge when medical professionals are screening for abuse versus non-accidental trauma.
Statistics show that in the year of 2020, one in five elders were abused and/or neglected. The mistreatment of the vulnerable people in our society was primarily carried out by a family member, who often embodies the role of a caretaker for the elderly.
As a nurse who has spent the past decade auditing emergency room records, I’ve seen too many children under 5 present to the ER with questionable injuries such as head trauma, fractures of the long bones, bruising and overdoses from illicit substances by accidental injection. I still remember my clinical rotation in nursing school. These took place in multiple nursing homes for the elderly as well as the VA (Veterans Hospital) in Brentwood. I saw subpar care, which unbeknownst to me at the time, can cause a rapid decline in a medically compromised patient. I learned the importance of pressure ulcer prevention, wound care, and proper medication management, as medication administration errors can be fatal, whether by omitting to administer a medication, or administering an incorrect dose causing toxicity.
In the event that neglect or abuse is suspected, a child/elder abuse concern is documented by reporting it to the proper agency for further investigation. Common allegations stem from neglect, physical abuse or the depravation of a child/adult of adequate nutrition. Regardless of the reason a family finds themselves in juvenile dependency court, as well as the case where a loved one is mistreated at a healthcare facility, the process is stressful, draining and depending on the outcome, can change the family unit as a whole.
Medical records can be an intricate part of an individual's or organization's defense, yet they are often overlooked.
When medical malpractice is suspected, medical records contain most if not all of the answers, even when altered with changes made retrospectively, there are avenues one can take to ensure the medical records available contain a proper addendum or reason for the amendment made. While falsifying medical information on records is illegal, adding an addendum in the event that additional information becomes available is allowed, as long as that change is properly documented.
When a parent gets accused of maltreatment of their child, medical records from their birth, any hospitalizations, pediatric visits, emergency room documentation can contain exculpatory evidence. A thorough review of the medical records available for a child, or in some cases, an adult, allows the attorneys working on the case to get a full picture of what occured.
Medical records can be an intricate part of an individual's or organization's defense, yet they are often overlooked.
When medical malpractice is suspected, medical records contain most if not all of the answers, even when altered with changes made retrospectively, there are avenues one can take to ensure the medical records available contain a proper addendum or reason for the amendment made. While falsifying medical information on records is illegal, adding an addendum in the event that additional information becomes available is allowed, as long as that change is properly documented.
When a parent gets accused of maltreatment of their child, medical records from their birth, any hospitalizations, pediatric visits, emergency room documentation can contain exculpatory evidence. A thorough review of the medical records available for a child, or in some cases, an adult, allows the attorneys working on the case to get a full picture of what occured.
NEGLECT (General/Medical)
Neglect; an allegation of neglect asserts that the child was not receiving adequate care, supervision, medical treatment, housing, and/or nutrition necessary to ensure the safety and health of the child. A medical record review would identify the child's weight and growth trends from birth to current state which could explain a child's size or growth curve. Review and documentation of all immunizations received could prove that the child was indeed receiving regular medical examinations, countering the medical neglect allegation. The presence of any absorption disorders could explain why there was a concern of malnutrition.
Part of what I do includes going back to birth, identifying any relevant elements and creating a timeline which reflects the child's growth and development based on assessments conducted and reflected in the available records. I document any instances of illness or hospital admissions which could have been a direct cause of the child losing weight. I identify whether medical records support the child/adult having been referred for feeding therapy services, a swallow test study, or other interventions to rule out underlying causes that lead to weight loss, independent of intentional starvation of the child.
Part of what I do includes going back to birth, identifying any relevant elements and creating a timeline which reflects the child's growth and development based on assessments conducted and reflected in the available records. I document any instances of illness or hospital admissions which could have been a direct cause of the child losing weight. I identify whether medical records support the child/adult having been referred for feeding therapy services, a swallow test study, or other interventions to rule out underlying causes that lead to weight loss, independent of intentional starvation of the child.
FAILURE TO THRIVE
"Failure to Thrive" is sometimes diagnosed in a child that does not gain enough weight or fails to reach the linear growth of other children of the same age. A child may fall below the 5th percentile for height and/or weight on the growth chart. Since a child is clinically considered "failure to thrive" when their growth falls below the 5th percentile, these children often raise suspicion for inadequate food intake as a result of their respective caregiver. I often see this diagnosis in cases of twin pregnancies, however singleton pregnancies' are also affected.
What I do in these cases is establish the child's weight and length at birth, determine whether there was any intrauterine diagnosis of growth restriction (IUGR) or small for gestational age (SGA). In the event that the child was premature, an adjusted age is used to calculate their personal growth curve, as it will differ from that of a child born at 40 weeks gestation. These cases always need a weight chart to monitor the growth and identify spikes or drops in the child's trending weight/height. If the child stayed in the NICU (neonatal intensive care unit) after birth, I document the LOS (length of stay), reason for admission as well as any interventions or testing conducted during that time. In the case of twin pregnancies, an important consideration worth documenting is if the twins shared a placenta, whether there was record of one of the babies getting more nutrients than the other. These considerations can provide a medical explanation why the child is on the smaller side with a FTT diagnosis.
What I do in these cases is establish the child's weight and length at birth, determine whether there was any intrauterine diagnosis of growth restriction (IUGR) or small for gestational age (SGA). In the event that the child was premature, an adjusted age is used to calculate their personal growth curve, as it will differ from that of a child born at 40 weeks gestation. These cases always need a weight chart to monitor the growth and identify spikes or drops in the child's trending weight/height. If the child stayed in the NICU (neonatal intensive care unit) after birth, I document the LOS (length of stay), reason for admission as well as any interventions or testing conducted during that time. In the case of twin pregnancies, an important consideration worth documenting is if the twins shared a placenta, whether there was record of one of the babies getting more nutrients than the other. These considerations can provide a medical explanation why the child is on the smaller side with a FTT diagnosis.
PHYSICAL ABUSE
Physical abuse is suspected when a child is found to be suffering from bruising, lacerations, fractures or head trauma without a plausible explanation that provides an accidental cause. Physical abuse is especially concerning in an immobile child (a child too young to walk or move around freely). Referrals for physical abuse can come from a school, a pediatrician or a hospital, but any mandated reporter is bound by law to report a suspicion of physical abuse. Allegations of physical abuse are often complex and require a significant amount of testing and research to discover an alternate cause, assuming one exists. Bruising, especially patterned bruising, is often a strong indicator that a child may have been abused. Due to the fact that most immobile children cannot talk, answers for the bruising can be found in the medical and genetic records. Bone fractures can at times be explained by indicators in the medical records, such as laboratory results drawn as early as birth.
What I do in cases where allegations of physical abuse exist, is review the laboratory findings specific to bone health and document any changes in the levels, noting if these changes were possibly a result of supplementation or other medications. I review hospital records, as a finding of fractures usually results in an admission. I note what each specialist concluded, and often find that the specialists tend to disagree with each other's theories. If there is an allegation of pain and suffering, I document every pain assessment conducted on the child, as well as any pain medication prescribed during the admission. I document subtle differences in the interpretations of the imaging by the reviewing radiologists, as well as the presence of a "running diagnosis" which often leads to confusion and misdiagnosis when a multidisciplinary approach is used.
What I do in cases where allegations of physical abuse exist, is review the laboratory findings specific to bone health and document any changes in the levels, noting if these changes were possibly a result of supplementation or other medications. I review hospital records, as a finding of fractures usually results in an admission. I note what each specialist concluded, and often find that the specialists tend to disagree with each other's theories. If there is an allegation of pain and suffering, I document every pain assessment conducted on the child, as well as any pain medication prescribed during the admission. I document subtle differences in the interpretations of the imaging by the reviewing radiologists, as well as the presence of a "running diagnosis" which often leads to confusion and misdiagnosis when a multidisciplinary approach is used.
SEXUAL ABUSE
Sexual abuse is defined as any sexual act perpetrated against a minor (a person under the age of 18 in California) by an adult (over the age of 18 in California) through touching, inappropriately exposing body parts, penetration, sexual intercourse, introducing minor to/showing minor pornographic videos, encouraging inappropriate sexual behavior between minors or a minor and adult, human trafficking and sexual exploitation. Sexual abuse can occur at the home of the victim or in out of home care. Mandated reporters who work with children in any capacity are required to be cognizant of the signs of sexual abuse when assessing minors in any capacity.
Sexual abuse cases can be complex as there is often limited documentation available for review from the time the abuse likely occurred. Disclosures of sexual abuse can surface years after the egregious act. I have found through my reviews that subtle signs often exist on routine medical examinations, well child visits. The presence of chronic UTIs (urinary tract infections) and unexplained enuresis (bed wetting) in children are always noted in my review. Diagnoses such as PID (pelvic inflammatory disease) are worth noting, as well as behavioral changes documented by therapists, clinicians and the child's caregivers. The presence of absence of therapy directed to address the trauma is noted, and may further explain secondary diagnoses given by physicians assessing the victim as an adult.
Sexual abuse cases can be complex as there is often limited documentation available for review from the time the abuse likely occurred. Disclosures of sexual abuse can surface years after the egregious act. I have found through my reviews that subtle signs often exist on routine medical examinations, well child visits. The presence of chronic UTIs (urinary tract infections) and unexplained enuresis (bed wetting) in children are always noted in my review. Diagnoses such as PID (pelvic inflammatory disease) are worth noting, as well as behavioral changes documented by therapists, clinicians and the child's caregivers. The presence of absence of therapy directed to address the trauma is noted, and may further explain secondary diagnoses given by physicians assessing the victim as an adult.
EMOTIONAL/PSYCHOLOGICAL ABUSE
Emotional and psychological abuse is not comprised of physical acts or harm per se. The abuse is perpetrated by intentional infliction of emotional distress through words, threats and intimidation. Placing a child in a state of apprehension or fear by verbally berating them for minor indiscretions is emotional abuse. Emotional abuse, while not a physical act can be inflicted by physically destroying a child's personal possessions, breaking/throwing items to place the child in fear of potential harm. Hurting a loved one in front of the child (such as their mother, father or another sibling) for acts the child allegedly did as a form of punishment. Humiliating a child or calling them offensive names. Dismissing their needs or on the contrary, overly controlling behavior by the caregiver such as surveillance of the child in a place privacy would reasonably be expected.
In my experience documentation to support an allegation of emotional abuse is often found in IEPs (Individual Education Plan) for a school aged child. Behaviors such as aggression, fear without provocation, paranoia, hyperactivity or disruptive behavior in class, a lack of confidence and low self-esteem or a sudden change in academic performance are all signs that are worth noting in a review. It's important to list any disclosures that child made to draw the difference between emotional abuse that may be occurring at home versus bullying that's occurring at school. Any available notes with the school counselor or suspensions will help construct a timeline of when the behavior started and co-existing events that may have caused the change.
In my experience documentation to support an allegation of emotional abuse is often found in IEPs (Individual Education Plan) for a school aged child. Behaviors such as aggression, fear without provocation, paranoia, hyperactivity or disruptive behavior in class, a lack of confidence and low self-esteem or a sudden change in academic performance are all signs that are worth noting in a review. It's important to list any disclosures that child made to draw the difference between emotional abuse that may be occurring at home versus bullying that's occurring at school. Any available notes with the school counselor or suspensions will help construct a timeline of when the behavior started and co-existing events that may have caused the change.
BRUISES
Ecchymosis is a medical term to describe skin discoloration that occurs due to ruptured blood vessels just below the epidermis. Bruising presents as a skin discoloration due to the bursting of larger vessels, often resulting in a hematoma (blood pooling at the site of injury). Bruising discovered on an immobile child as well as bruising in specific locations on a child of any age, where accidental trauma is unlikely, is usually deemed to be a sequela of non-accidental trauma otherwise known as physical abuse.
While bruising and ecchymosis are used interchangeably in the medical world, they are vast differences when reviewing skin discoloration for the purpose of determining the cause. Bruising of the skin requires some inflicted force at the site due to the pooling of the blood, which is a body's natural response to injury. Ecchymosis however, is not always the result of a direct injury. This can pose a challenge when conducting medical record review of photographs of skin discoloration because bruises and ecchymosis are difficult to distinguish based on photographs alone.
In the event that there is a concern for "bruising", I start by reviewing laboratory results, if available. I look for factors that would indicate a vitamin deficiency such as Vitamin K or iron. I would additionally extract any work-up done by a specialist, such as a hematologist to determine whether a potential bleeding disorder was diagnosed even as early as birth. Available genetic records serve as a great source for obtaining the patient's family history and any disorders that could have been inherited, causing bruising or ecchymosis absent a direct impact from trauma inflicted trauma.
On the contrary, absent any explanation extracted from the medical record about existing bleeding disorders, deficiencies or medications the side effects of which could be "easy bruising" (blood thinners), the record may indicate that the bruise was indeed inflicted by a direct blow or applied pressure.
While bruising and ecchymosis are used interchangeably in the medical world, they are vast differences when reviewing skin discoloration for the purpose of determining the cause. Bruising of the skin requires some inflicted force at the site due to the pooling of the blood, which is a body's natural response to injury. Ecchymosis however, is not always the result of a direct injury. This can pose a challenge when conducting medical record review of photographs of skin discoloration because bruises and ecchymosis are difficult to distinguish based on photographs alone.
In the event that there is a concern for "bruising", I start by reviewing laboratory results, if available. I look for factors that would indicate a vitamin deficiency such as Vitamin K or iron. I would additionally extract any work-up done by a specialist, such as a hematologist to determine whether a potential bleeding disorder was diagnosed even as early as birth. Available genetic records serve as a great source for obtaining the patient's family history and any disorders that could have been inherited, causing bruising or ecchymosis absent a direct impact from trauma inflicted trauma.
On the contrary, absent any explanation extracted from the medical record about existing bleeding disorders, deficiencies or medications the side effects of which could be "easy bruising" (blood thinners), the record may indicate that the bruise was indeed inflicted by a direct blow or applied pressure.
DATING BRUISES/ECCHYMOSIS
Nurses are trained to correctly identify a bruise, properly document a bruise (size, color, edges, location and pattern). It's also important to understand that bruising will present differently on darker skin, sensitive skin and mottled skin.
Bruises go through a healing stage which begins with the appearance of a bruise where the color is saturated, sometimes the bruise is raised, accompanied by swelling and/or an abrasion. A bruise's morphology will change over the course of approximately 2 weeks, but depending on factors unique to the patient, healing may be delayed.
In my experience, bruising can be dated, however the science is not exact or absolute. There are certain caveats a nurse can find in the medical record to establish whether the bruising occurred within the last few days or up to a week prior to presentation. In the event that photographs are available in the medical record, a focused analysis can be tremendously helpful in all cases, from allegations of child abuse to neglect or elder abuse in a nursing home.
A notable finding is the observation of skin maturation or skin remodeling at site of the bruise, as this will determine the approximate healing stage. I also look for alternate explanations for the bruising which can easily be glazed over as it may seem insignificant, its very clinically significant. The placement of the bruising as well as the pattern can indicate a patient transfer injury where the proper technique was not utilized by a respective caregiver. This is important when differentiating bruises resulting from intentionally inflicted trauma from negligence by a caregiver resulting in accidental bruising.
https://www.medicalnewstoday.com/articles/322742#bruise-colors
Bruises go through a healing stage which begins with the appearance of a bruise where the color is saturated, sometimes the bruise is raised, accompanied by swelling and/or an abrasion. A bruise's morphology will change over the course of approximately 2 weeks, but depending on factors unique to the patient, healing may be delayed.
In my experience, bruising can be dated, however the science is not exact or absolute. There are certain caveats a nurse can find in the medical record to establish whether the bruising occurred within the last few days or up to a week prior to presentation. In the event that photographs are available in the medical record, a focused analysis can be tremendously helpful in all cases, from allegations of child abuse to neglect or elder abuse in a nursing home.
A notable finding is the observation of skin maturation or skin remodeling at site of the bruise, as this will determine the approximate healing stage. I also look for alternate explanations for the bruising which can easily be glazed over as it may seem insignificant, its very clinically significant. The placement of the bruising as well as the pattern can indicate a patient transfer injury where the proper technique was not utilized by a respective caregiver. This is important when differentiating bruises resulting from intentionally inflicted trauma from negligence by a caregiver resulting in accidental bruising.
https://www.medicalnewstoday.com/articles/322742#bruise-colors
BONE FRACTURES
A nurse is not trained on reading or interpreting radiology imaging or diagnosing any kind of fracture. A nurse is however trained on understanding the different types of fractures (displaced vs non-displaced, open vs closed, commuted vs hairline). Additionally, a nurse is trained on understanding terms used with osseous findings (Linear lucency, callous formation, growth plate injuries, salter Harris injury). Nurses are trained on obtaining blood work for laboratory tests and in turn have to know what the test is for, the pediatric and adult range used to interpret the result and what deficiencies, if any, are attributed to bone health and development.
I always defer any diagnosis or treatment recommendations to the orthopedic specialists, as that is beyond my scope of practice and knowledge.
What I look for when reviewing medical records where there is a clinical finding of broken bones, whether for a physical abuse or medical malpractice case, I always start with the laboratory tests and results. If the case pertains to an older child, there are bone density tests that are often administered to rule out brittle bone disease, these, if available, would be included in my review. On the contrary, if I find that specific testing was recommended but not carried out, I would make note of the facility, provider and date when the referral was made.
One of the bone cases I reviewed was over 10,000 pages long, and there was one urine test performed that indicated slow bone turnover. As detailed as I am, I had missed it. Thankfully I had my colleague take a second look and they found it. I like to say it's always good to have a fresh set of eyes who are trained in finding medical errors, take a second look.
I always encourage anybody facing with a complex medical case to do their own research. I am including some helpful articles below that touch on a number of important topics.
Psychological Bonding Evaluations in Termination of Parental Rights Cases
https://www.academia.edu/115536496/Psychological_Bonding_Evaluations_in_Termination_of_Parental_Rights_Cases?source=news_feed_share
Pressure points: learning from Serious Case Reviews of failures of care and pressure ulcer problems in care homes
https://www.academia.edu/122662449/Pressure_points_learning_from_Serious_Case_Reviews_of_failures_of_care_and_pressure_ulcer_problems_in_care_homes?source=swp_share
Child Sexual Abuse is "Silent Problem"
https://www.academia.edu/97477063/Child_Sexual_Abuse_is_Silent_Problem_?source=swp_share
Distinguishing child abuse fractures from rickets
https://www.academia.edu/52891655/Distinguishing_child_abuse_fractures_from_rickets?source=swp_share
Psychological Bonding Evaluations in Termination of Parental Rights Cases
https://www.academia.edu/115536496/Psychological_Bonding_Evaluations_in_Termination_of_Parental_Rights_Cases?source=news_feed_share
Pressure points: learning from Serious Case Reviews of failures of care and pressure ulcer problems in care homes
https://www.academia.edu/122662449/Pressure_points_learning_from_Serious_Case_Reviews_of_failures_of_care_and_pressure_ulcer_problems_in_care_homes?source=swp_share
Child Sexual Abuse is "Silent Problem"
https://www.academia.edu/97477063/Child_Sexual_Abuse_is_Silent_Problem_?source=swp_share
Distinguishing child abuse fractures from rickets
https://www.academia.edu/52891655/Distinguishing_child_abuse_fractures_from_rickets?source=swp_share
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© 2021 by Charting Compliance. All Rights Reserved.
© 2021 by Charting Compliance. All Rights Reserved.