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Plaintiff falls, breaks hip: Defense verdict returned
By Radha V. Bachman, Esq.
Buchanan Ingersoll & Rooney PC
Leilani Kicklighter, RN, ARM, MBA, CPHRM,
The Kicklighter Group
News: A man slipped and fell while getting out of his hospital bed, causing him to suffer a fractured hip and leg. The man and his wife sued the hospital for negligence, claiming that he had not been fitted with "gripper socks" and that nurses had not responded after the man had attempted to call them with the call light. A jury determined that the hospital had not been negligent and returned a defense verdict.
Background: A 60-year-old man was hospitalized for conservative care and rehabilitation after falling at home and suffering a pelvic fracture. A patient in the hospital's transitional care unit, the man then slipped and fell again as he attempted to get out of his hospital bed. He suffered an interochanteric fracture of his right hip and a fracture of his right femur.
The man and his wife sued the hospital for negligence, claiming that the man's fall was caused by the hospital's failure to fit him with "gripper socks" as required by hospital policy and by the nurses' failure to help him get out of bed. The plaintiffs specifically alleged that at the time of the fall, the man was confused and disoriented due to the pain medications he was taking. They also claimed that the nurses were aware that the husband was confused and had been trying to get out of bed without assistance, and yet they failed to call the doctor for orders or otherwise take steps to prevent a fall. Finally, the plaintiffs alleged that the man had used his call light to ask for assistance to the bathroom, but when no one came, he attempted to get up on his own and fell on the "slippery" floor. The plaintiffs contended that the delay in responding to the call light was substandard and that if basic fall precautions had been taken, as required by the hospital's policies and procedures, the man's fall would have been prevented.
The husband's alleged damages were $30,000 in medical costs and an unspecified amount for pain and suffering. He claimed that he suffered substantial leg shortening as a result of his injuries, and that he would walk with a limp for the rest of his life. The woman's alleged damages were $6,000 in lost wages, attributable to the fact that she had to take off work to care for her husband.
The hospital defended the suit, claiming that basic fall precautions were in place and that the man had been told not to get out of bed without using the call light to call for assistance. The hospital also denied that the man had called for assistance before his fall. After a jury trial, a defense verdict was returned.
A similar case took place in New Jersey where a jury exonerated a hospital nurse from allegations of negligence. In that case, the patient testified she rang her call buzzer for 30-45 minutes for help to get up to go to the bathroom, then got up on her own, leaned on a rolling tray table, fell and broke her hip. The nurse testified that she talked with the patient and wrote a progress note right after the fall about why the patient herself believed she had fallen. The patient said she wanted to get up and see what was going on the other side of the room and tripped on the leg of the tray table. She never mentioned her call bell not working or not being answered.
The first three days after her liver biopsy, the patient was handled as a high fall risk. She fell on the fourth day after the biopsy. Her physician had written an order for ad lib bathroom privileges. At the time of her fall, she was no longer a high fall risk and was in the hospital for observation.
What this case means to you: Falls and fractures usually are associated with the elderly and nursing homes, or youngsters falling or breaking bones during sporting events. Complications from fractures and head injuries are a well-known sequel of falls. Osteopenia and osteoporosis are underlying diseases and conditions that make a simple fall a higher risk to fracture.
Fall prevention is a focus of the patient safety initiative. While there are general interventions that can apply to any setting to prevent falls, some are tailored to a specific setting. For instance, hospitals, nursing homes, and other health care facilities should not have "throw" or small area rugs, as they tend to slip or wrinkle. In the home, use of those small rugs is discouraged, but when they are used, it is recommended that double-stick tape be used to secure them to the floor. Health care facilities should consistently evaluate the floor "wax" or protective coating in order to determine the "slip factor" and prevent falls. "Wet-floor" signs and other notices and barriers can go a long way in preventing injuries that occur as a result of unnecessary falls.
Each and every patient needs to be fully evaluated for fall risk on admission, periodically thereafter, and when there is a significant change in the patient's condition. Underlying illnesses, medications, conditions, or sedentary lifestyles can lead to deterioration of muscle strength, balance problems, or confusion that can increase a patient's risk of falling.
Risk managers should review their organization's fall prevention policy and procedure in detail, including the assessment tool. As a part of that assessment, the risk manager should make rounds on the units that report the highest incidence of falls to informally survey staff regarding causation. Such a survey would glean the understanding and follow-through by staff to implement the fall risk interventions detailed in the facility's policy and procedure manual. Barriers to complying with the fall prevention policy and procedure might also be identified. If slip-resistant socks or other devices are a part of the fall prevention policy, assessment that there is an adequate supply available is vital.
Part of the admission process should be to do a fall risk assessment. Based on the assessment, following the policy and procedure, interventions to prevent or reduce the risk of fall should be implemented and added to the patient's care plan. In this case, it is unknown if the slip-resistant socks were a part of the policy and procedure and, if so, whether they were actually supplied to the patient. When a patient with a known fall and fracture that resulted from the fall is admitted to a rehab center, the fall prevention activities should be a usual and customary practice for most of their patients.
Again, depending on the facilities' policy and procedure, that is the first line of prevention and defense; other interventions might be toileting rounds, or rounds to verify the call bell is within easy reach of the patient and that it works. The level of the bed should be assessed and set with the patient depending on his or her mobility and condition. A bedside commode is sometimes a part of the fall prevention procedure to make it easier for an alert, heretofore independent patient to take care of these needs if help is not readily available. It is important that whatever the intervention/prevention steps are that they are implemented and assessed periodically, and that they are in place on an ongoing basis.
Based on the facts detailed in the first situation, the patient came in to this rehab facility with a known risk for falling, having fallen at home and suffered a fractured pelvis. Rehab facilities, as a part of their rehabilitation services, work with patients to provide rehab services to return the patient to independent living as much as possible. Parts of those rehab services include increasing stability or fall prevention with adaptive devices or strengthening muscles.
According to Patricia S. Calhoun, JD, RN, of Tampa, FL-based Buchanan Ingersoll, the reason for a defense verdict in the second case is quite clear. First, the patient was not a high fall risk patient; she was on "activity ad lib" and this note shows no reason for any further fall precaution. The high fall risk initially ordered after the liver biopsy was simply a precaution in case she suffered a post-procedure complication such as internal bleeding, which could cause hypotension (often a cause of falls). Calhoun notes that the most important lesson here is the importance of documentation. Calhoun stresses the critical nature of the nurse's documentation of her conversation with the patient contemporaneously with the event, since it is likely that this documentation "proved" to the jury that the patient's account of the episode was inaccurate.
One complaint patients make on a frequent basis is that call lights are not answered on a timely basis. Many patients, particularly many in rehab centers, are accustomed to being independent and not relying on someone to help them in their activities of daily living (ADLs). While patients are educated to call for someone to assist, when they comply and the promised assistance is not forthcoming, they will sometimes take it into their own hands. This is particularly true when it involves a need to use the bathroom. This is an ongoing problem in all health care facilities, that is, how to promptly respond to a call light when all staff are busy assisting other patients, especially in light of lower patient-to-staff ratios. Response should be assessed by the relevant staff and administration.
While facilities often provide inservice education sessions to staff to emphasize those issues after such an unfortunate incident, often that is of little effect. If the risk manager were to interview each member of the staff, it is probable that all would indicate knowledge of the need to promptly respond to call bells, to conduct frequent toileting rounds, and what the policy and procedure for fall prevention entails. Further, staff might share in such interviews the barriers to compliance, such as staffing levels, frustration, leadership, teamwork, and other issues that would need to be and should be addressed.
Above all, the risk manager should conduct a root-cause analysis of this event to determine the basic cause of the failure of the facility's fall prevention interventions. The staff who are a part of such a root-cause analysis often learn more from this process than an inservice presentation. Being a part of the solution to correct and prevent another such incident often empowers staff, reduces frustration, and ultimately increases patient safety.
Case No. VC046949, Los Angeles County Superior Court.
Superior Court of New Jersey, Appellate Division.