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By Pearl Schaikewitz, JD
Legal Consultant, Atlanta
News: The estate of a psychiatric patient who collapsed and died 45 minutes after being choked by another patient won a $642,730 verdict against the facility. The nurses didn't call a physician to examine her after the incident.
Background: The 70-year-old woman had been diagnosed with bipolar disorder and schizophrenia and was a longtime resident of the intermediate care facility for mentally impaired adults. On April 29, 1993, she was attacked by another patient, who choked her with a scarf and hit her in the face. That patient was a paranoid schizo phrenic. Another resident immediately alerted the nursing staff. According to the nurses, the patient who had been attacked said she was not injured, so they allowed her to leave the nurses' office unattended to smoke a cigarette. About 45 minutes later, when the police wanted to interview the victim, the nurses found her in her room, short of breath. They asked her to walk to the nurses' station, but she collapsed and lost consciousness. She was pronounced dead on arrival at a nearby hospital.
The patient's daughter claimed that after the attack, her mother was bleeding from the mouth and had bruises on her face and neck. She maintained that the facility was negligent in failing to assess her mother's injuries, to call 911 or a physician, or to make appropriate efforts to resuscitate her. Experts testified for the plaintiff that the patient had sustained fractures to the hyoid bone and anterior neck cartilage, which, when left untreated, resulted in swelling, hemorrhaging, an obstructed airway, suffocation, cardiac arrest, and death. Those experts concluded that the patient's nursing care was inadequate and that her injuries would not have been fatal if treated in a timely manner.
The facility countered that the patient's vital signs were normal after the attack and that the nurses were unaware at the time of their initial assessment that the patient had sustained throat fractures. The facility's insurance carrier disputed coverage and refused to increase its settlement offer despite the recommendations of its trial counsel and two judges.
What it means to you: Phyllis Maxey, RN, director of risk management for Carolinas HealthCare System in Charlotte, NC, first wonders whether the attacker had a history of violence. "The victim had been a long-term resident, so the staff probably knew her pretty well. But we do not know how long the perpetrator had resided in the home, so we do not know how well the staff knew him. So my first concern was the history of both patients. Were they known not to get along?"
Incompatibility problems highlight the need for monitoring, Maxey stresses. "Where were these patients located when the incident occurred, and was there sufficient staff in attendance to monitor them? This case illustrates why, even though you believe psychiatric patients have progressed to a certain level, you cannot relax in your vigilance in monitoring them. Had an attendant witnessed the attack, that person might have prevented the nurses from making an incorrect assessment. If you see a particularly vicious or aggressive attack, that will color how well you assess the patient," she notes. She suspects these patients were in the day room when this happened and says the facility should have a policy in place stating that those patients should be attended.
Another concern Maxey has is the daughter's allegation that her mother was bleeding from the mouth and had bruises on her face and neck. "We do not know what physical signs the nurses had to go on. But if there were signs of injury on the patient's face and neck, they would have to be taken very seriously, given the proximity to the airway. Similarly, allowing the patient to leave the nurses' station and go unattended to smoke a cigarette was dangerous, because that activity affects the airway.
"A patient who has suffered an attack needs to be watched to make sure that she is truly not injured, as she has reported. So, I would have to question the nurses' judgment. If they let her smoke, it was probably outside, and that is pretty far away from the nurses' station," she says. Maxey adds that the bruises might not have appeared at the time the nurses first saw the patient after the attack. "But if it is true that the patient was bleeding from the mouth and she had a large, swollen hematoma on her lip, it should have been apparent when the nurses saw her."
Patient's appearance, statement insufficient
Maxey also wonders about the details of the examination the nurses conducted after the incident. "Making an overall appearance assessment is not sufficient. One cannot rely entirely on a patient's statement that she is fine, because that is entirely subjective. The patient may be embarrassed and may wish to minimize the incident."
There is a standard to comply with, Maxey adds. "Vital signs should have been taken at the time. Then the nurses could have asked the patient to sit in a chair attended by the nurse for 10 minutes, checked her vital signs again, and then re-checked them after another 15 minutes."
The nurses should have looked for any signs of bruising, such as a red, pressure-looking area and then noted it, she says. "After an incident such as this, the skin needs to be assessed for any kind of force or tear. Elderly people have thin skin, and changes would probably be apparent on the skin. A bruise would probably appear within 15 to 20 minutes. And, of course, the assessment must be documented."
Finally, Maxey says she does not think the evidence justifies the experts' conclusion that the patient's nursing care was inadequate and that her injuries would not have been fatal if treated in timely fashion. "It is possible that she could not have been saved even if the nurses had noted that she had been injured, had called 911, and medics had arrived timely. I believe that most likely her vital signs were normal when the nurses did a basic exam after the injury and that it was not until later, when her airway began to swell, that her vital signs changed."
Rogers v. Columbus Manor Residential Care Home Inc., Cook County (IL) Circuit Court, Case No. 94-L-1519.