This case involves a 67-year-old male patient who died after undergoing knee replacement surgery. Experts determined the defendant nurse breached the standard of care by failing to adequately assess and monitor the patient post-operatively. Specifically, the nurse did not properly document vital signs and checks on the patient. When the patient vomited after experiencing nausea, the nurse did not provide sufficient additional observation or notify the physician. This lack of appropriate care led to the patient becoming unresponsive and ultimately dying from anoxic encephalopathy. The court found the nurse negligent in her post-operative care of the patient.

1. Case Study Rubric
This assignment involves your having to do research. You
cannot rely on your textbook. So I will not “miss” any part of
your answer, be sure to label each question. Remember there are
more than one person involved in the case [See question 3].
Finally you MUST develop a risk management action plan.
ACTIO plan means you must do something. What-how?
Research [how to develop] an action plans.
Remember APA format is important [See Syllabus for “How-
To” Tips]. Also if you list a reference there should be an in-
text citation, and YES I do check references. Good Luck and
Happy Researching!
Points Possible
Points Earned
Explanation
Question #1
Summarize the Case and the verdict
10
Question #2
Based on YOUR review and summation, do you agree with the
court’s decision? DEFEND YOUR ANSWER.
20
Question #3
a. What practice related legal and/or ethical issue(s) [as they
pertain to Health Care Management] were breached?
b. How?
c. By Whom? (Include ALL the possible defendants)

2. DEFEND YOUR ANSWER [NOTE High Point Value]
20
Question #4
Identify and document a risk management action plan to prevent
this type of issue from reoccurring. [NOTE High Point Value]
.
20
Minimum scholarly references with in-text citations
10
Following of Directions:
1.APA Format
2.Not including cover and reference pages,
3.Not re-stating each question prior to answer
10
Multiple Grammatical/spelling/punctuation errors
NOTE how Points may be lost for NOT FOLLOWING
DIRECTIONS!
10
TOTAL Possible Points
100

3. Student Name: Joseph Moore
Project Name: New Software Development
1. Project Type
New Software Development- the purchasing business needs to
have long-term management preparation used for choosing,
approving and upgrading software programs such as commercial
off-the-shelf (COTS) and other software products which are
reusable. If a mixture of these constituents is increased in the
new systems, the demand continues to grow. The new software
management plan and COTS usually help to facilitate the
purchasing of new programs management of COTS and some of
the reusable software. The new COTS and reusable software
will provide the strategy that outline data management about
monitoring interdependency of software, tracking, choosing
specific features and documenting those choices. The reusable
software and COTS presented in this project functions as a
guide for how to accomplish new software components and
COTS in a complex system (Anderso,Smith and Ward, 2007).
2. Purpose
The purpose of this project is help in identifying the techniques
and collaborative processes in handling the new software
components, and to address the risks and other issues. Some of
the actions that must be taken to address the risk and issues
include identification of the components that can be shared
across the software system and encourage their use
(Anderso,Smith and Ward, 2007). Create COTS and software
component estimation process that helps to address
interoperability, other principles recognized in the Component
Assessment Standards and documented in the strategies of
Software Development Plan. Create COTS and software
tracking system which includes constituent information from
COTS dealers who often combine other components of COTS

4. into their products. Finally, enable the evolution of reusable
software component that is steady and dependable with curved
development model.
3. Scope
This project seeks to justify the new development on the
application of COTS solution. It also provides introductory
information about COTS and new software programs and
describes its relationship to other program plans
(Anderso,Smith and Ward, 2007). The COTS and new software
project planning applies to the business such as Unilever that
choose, assess and use software components. This includes
some of the techniques like tracking statement programs,
checking software interdependency, selecting exact features and
documenting those choices, assessing and alleviating the risks
related to COTS and new software component in a system. The
reusable software can be grouped into different categories of
components; some of them include Shareware, Commercial off-
the-shelf (COTS) and Government off-the-shelf (GOTS).
4. Goals and Deliverables
The main goals of the project include: to eliminate the baseless
production of similar but different software components which
are reusable across the organization and support the quantity
discounts if possible. Secondly is to describe strategies for the
program and approaches to managing and developing software
components and COTS, which provide an origin for supporting
roles and possesses (Anderso,Smith and Ward, 2007). Thirdly is
to provide a summary of roles of the program that are affected
by development plan and includes an overview of the operation
that supports the software plan strategies. Additionally, to
ensure software development plan is implemented by describing
the programs processes. Finally, to describe the activities that
exceeds the development of the systems and employs reusable
software components.
5. Required Resources
Resources are means used to achieve the objectives of the
project. The primary resource is people who have diverse skills

5. and five years’ experience in project management. They must
also be competent enough to carry out outstanding work.
Secondly, there is a need for adequate funds which helps the
project activities to run smoothly (Kerzner, 2013). The
equipment’s such as computers will also be required to keep
data collected during the project. Other materials include
notebook and pen. The availability of resources will give
freedom on completion of project activities. These resources I
gathered them at the beginning of the project.
References
Anderso, W., Smith, D., & Ward, M. C. (2007, October). COTS
and Reusable SoftwareManagement Planning: A Template
forLife-Cycle Management. Retrieved October 2015, from
software engineering institute:
https://resources.sei.cmu.edu/asset_files/TechnicalReport/2007_
005_001_14882.pdf
http://www.peterjoubert.com/resource-requirements/
Kerzner, H. R. (2013). Project management: a systems approach
to planning, scheduling, and controlling. John Wiley & Sons.
Project Charter
<Project Name>
<Student Name>
<Date>
Project Charter
<Project Name>
Project Manager:
Anticipated Start Date:

6. Anticipated End Date:
Project Summary
Summarize the project in one paragraph and what business
needs, problems or opportunities the project addresses – a
market demand, business need, legal requirement, social need,
customer request or technological advance.
Project Scope
State the anticipated scope of the project and its anticipated
deliverable(s) Identify what is going to be done, and what is
NOT going to be done.
Project Assumptions
What are the initial conditions for the project? What will the
final conditions be? What other assumptions have bearing on
the project? Are you targeting a specific platform, etc.? If
software is involved, will it be expected to run on mobile
devices? What kind of hardware might be involved?
Summary milestone schedule
Utilize some variation of the below, utilizing dates and
milestones that make sense for your project…
Feb 1, 20xx – Project Plan Complete and Approved
Mar 31, 20xx –Design Completed
May 31, 20xx – Coding Completed
June 30, 20xx – Testing Completed
July 31, 20xx – Beta Testing Completed
Sept 30, 20xx – Implementation Completed
Oct 15, 20xx – One Performance Cycle Complete and Project
Completion

7. Project Budget
Budget – state the “best guess” budget for the project and
identify funding sources…
project charter is a document that gives the project manager the
authority to execute a project and use organizational resources
for the purpose. It authorizes the initiation of a project. A
project charter includes basic project information, such as title
of the project, project objectives, project schedules, project
budget, success criteria, project management approach, roles
and responsibilities matrix, and so on.
Your work should be submitted in a Word document, 2–3 pages
in length, typed in double-space, in 10- or 12-point Times New
Roman font. The page margins on the top, bottom, left side, and
right side should be 1 inch each. You should use the APA
guidelines for writing and citations.
Case Study #1: Failure to adequately assess and monitor the
patient post operatively resulting in the patient’s death
NOTE: There were multiple co-defendants in this claim who
are discussed in this scenario. While there may have been
errors/negligent acts on the part of other defendants, the case,
comments, and recommendations are limited to the actions of
the defendant; the nurse.
The decedent/plaintiff was a 67 year old male who underwent a
right total knee replacement. Following the procedure, the
plaintiff was treated in the post-anesthesia care unit where an
epidural catheter was inserted for postoperative pain
management.
Following one episode of hypotension which was treated
successfully with ephedrine, the plaintiff was discharged to an
inpatient medical-surgical care nursing unit with the epidural in
place. Although the defendant nurse customarily worked on the
post-acute critical care unit, she had been re-assigned to the
medical-surgical nursing care unit. The defendant nurse stated
that she understood her assignment at the time of the plaintiff’s

8. admission to this unit was to provide oversight of the patient
care on the entire floor for that shift.
The defendant nurse assessed the plaintiff upon his admission to
the unit and found him to be stable. The defendant nurse
understood that the direct care of the plaintiff was assigned to a
c-defendant licensed practical nurse (LPN). Approximately
three hours after arriving on the unit, the plaintiff was unable to
tolerate ordered respiratory therapy due to nausea and vomited
shortly thereafter. According to the defendant nurse,
approximately ten minutes after the episode of vomiting, the
LPN found the plaintiff cyanotic and unresponsive and
immediately called a code.
The defendant nurse responded, as did the code team, and the
plaintiff was intubated and transferred to ICU. This account of
events was disputed by the LPN and two other staff on the unit
who understood that the defendant nurse was responsible for the
direct care of the plaintiff.
The LPN stated that it was the defendant nurse who found the
plaintiff to be unresponsive at some point after the episode of
vomiting and called the code herself. The elapsed time between
the episode of vomiting and the code is also disputed. The
eventual diagnosis was anoxic encephalopathy due to the time
that elapsed before CPR was initiated. The prognosis was poor
and life support was withdrawn. The plaintiff breathed
independently and was transferred to hospice care where he
subsequently expired.
Ordered vital signs and checks of the xyphoid process were not
documented. The fact that the plaintiff had experienced
hypotension in the recovery room should have warranted even
closer observation. The episode of nausea and vomiting should
have resulted in additional observation and notice to the
physician.
Resolution
Experts determined that the defendant nurse had breached the
standard of care.

9. Discussion
1. Summarize the case and the verdict.
2. Based on your review and summation, do you agree with the
court’s decision? Defend/discuss your answer.
3. What practice-related legal and/or ethical issues as they
pertain to Health Care management were breached? How? By
whom? Include the nurse as well as ALL other possible
defendants. DEFEND your answer.
4. Identify and document a risk management actionplan to
prevent this type of issue(s) from reoccurring.