Read this scenario. Decide if the situation presents potential elements of malpractice.

A 65-year-old female patient was taken to the emergency department (ED) after suffering a fall at home. Her husband had been away from the house several hours and when he returned home, he found her on the floor. The patient was confused, and no one was able to ascertain how long she had been lying on the floor.

She was taken to the nearest emergency department with complaints of weakness, confusion and right lower leg and foot pain. Her past medical history included Parkinson's disease, mild dementia, hypothyroidism and anxiety.

The radiology results revealed an open displaced fracture of the right tibia and fibula. An orthopedic surgeon requested the patient be prepped for surgery. However, there was over a four hour delay getting the patient to surgery for various reasons.

The patient underwent surgery which lasted approximately three hours. In the intraoperative nursing (pre-operative and post-operative) assessment, documentation regarding skin integrity was incomplete as well as documentation of the position aides.

The patient was taken to the surgical floor with orders to be placed on the post-surgery protocol. The protocol included comprehensive orders for vital signs, pain control, nutrition, hydration, mobilization and skin integrity prevention measures. The admitting nurse assessed the patient's skin and gave her a risk score of 14 according to the Braden Scale (the lower the number, the higher the risk to develop pressure ulcer). The hospital's "Alteration in Skin Integrity" protocol required an air mattress for any patient with a score of less than 18.

Although the admitting nurse ordered medical air mattress overlay for the patient, the hospital did not have any available. A request for a mattress was placed with an outside vendor, but since it was a holiday weekend the delivery of the mattress would take at least eight hours. The following day (post-operative day one), the day shift nurse assessed the patient and documented a skin assessment score of 20.

Skin assessments and repositioning documentation were missing on several shifts, despite hospital policy. Skin checks are required once a shift and skin integrity protocols require repositioning a patient every two hours.

On post-operative day three, the night shift nurse reported the presence of a purple localized area of discolored intact skin on the patient's sacrum. However, it wasn't until the night nurse returned that the patient was finally placed on an air mattress. On post-operative day five, the patient was discharged to a local skilled nursing facility. The patient's admitting diagnosis to the skilled facility was status-post operative leg surgery, Parkinson's disease, mild dementia, hypothyroidism, anxiety, anemia and Stage IV decubitus ulcer.

Over the next nine months the patient suffered from infections, debridement and anemia all related to the sacral ulcer. At one point the size of the ulcer was 8.5 cm in length, 7cm in width and 4 cm in diameter. To prevent further infections the patient underwent a sigmoid loop colostomy, a sacral osteotomy and a second bilateral gluteal flap repair for the non-healing ulcer. A urinary catheter was used to prevent further skin breakdown and since the patient struggled with malnutrition due to infection, a gastrostomy tube was inserted during one of her hospitalizations.

The patient died 10 months after her fall.

1. List the 4 elements of a malpractice claim and, for each of the 4 elements, state which, if any, of the facts in the scenario support that specific element.