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Nursing Home Resident Dies After Fall; $900K Verdict
NEWS: An 83-year-old man was admitted to a nursing facility after suffering a broken hip and a stroke. The hospital, prior to discharge, determined that the man required 24-hour stand-by assistance for all movement. The admitting nurse at the nursing facility, however, assessed the man and determined that he was independent in ambulation and needed no assistance for daily routine activities. Shortly after being admitted, the man fell. On the third day after being admitted, a fire broke out in the facility. During the evacuation process, the man fell again and dislocated his previously fractured hip. The man was taken to a hospital, where his hip was dislocated six additional times. The man died three months after first being admitted to the nursing home of complications from the hip fracture and dislocations. A verdict in favor of the plaintiff was entered in the amount of $915,397.
BACKGROUND: An 83-year-old man was admitted to the hospital for the repair of his broken hip. While in the hospital following surgery, the man suffered a stroke, leaving him paralyzed on his left side. The stroke and subsequent paralysis left the man with significant problems ambulating. It was at this time that the man was assessed, and it was determined that he required 24-hour stand-by assistance for all movement.
Subsequently, the man presented to a local nursing home. At the time of admission, the admitting nurse assessed the man as being independent in ambulation and needing no assistance for daily routine activities. It was also noted that the man had made a good recovery from the stroke and only needed around-the-clock supervision. Shortly after being admitted to the facility, the man fell. Three days after admission, a fire broke out during the night shift in the nursing facility, requiring evacuation of the residents. The man was not assisted in the evacuation, as there was only one nursing aide on the floor that evening for 24 residents. During the evacuation, the man fell, despite use of a four-point walker. The man's previously dislocated hip was fractured. The fractured hip was identified by nursing home staff at the time residents were allowed to reenter the building. The man was taken to the hospital, where he suffered six additional dislocations. Due to the circumstances, the man's condition further deteriorated, and he suffered kidney failure, underwent surgery on the hip, and contracted a hip infection. The man ultimately died.
The plaintiff in this case alleged many errors on the part of nursing home personnel. Specifically, the plaintiff contended that the man was admitted to the facility without proper evaluation. Additionally, the plaintiff claimed the nursing home's failure to conduct another evaluation of the man after the first fall was a deviation from the standard of care. With respect to the second fall that occurred during the fire evacuation, the plaintiff alleged that the man was overmedicated, which contributed to his fall and the complications leading ultimately to his death.
The defendant countered the plaintiff's claims and contended that the nursing home was not provided with the man's medical records upon admission. The defendant also denied that the man was overmedicated or that his hip was fractured because of the fact that the man never complained of pain when he was carried out of the facility by a firefighter attending to the situation.
The jury in the case returned a verdict in favor of the plaintiff in the amount of $915,397.
Portage County (WI) Circuit Court, Case No. 06 CV 63.
WHAT THIS MEANS TO YOU: In this case of an 83-year-old gentleman with a history of hip fracture and subsequent stroke, who was discharged from a hospital to a nursing facility, appropriate and ongoing assessment is central to the verdict for the plaintiff. Considering life expectancy, his age and death were most likely primary factors in determining the amount of the verdict, particularly in light of the breach of duty, resulting injuries, and causation in this case. The failure to adequately assess the resident, resulting in multiple dislocations, complications, and ultimate death could otherwise have led to a higher dollar verdict.
The hospital assessment indicated the patient required 24-hour stand-by assistance for all movement. The fractured hip history, followed by a stroke and subsequent left-sided paralysis, were but a few of the risk factors for falls. The nursing facility's claim of not being provided the patient's medical records upon admission to the nursing facility was a poor excuse inappropriate and unacceptable. According to the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission, it is the responsibility of the health care organization, whether in an acute or long-term care setting, to adequately and appropriately assess and periodically reassess the patient or resident. This is not optional. The nursing facility was responsible for performing an intake assessment prior to admission to determine if they could accept the patient and meet his needs, and were responsible for performing an admission assessment once the patient was discharged from the acute care setting and became a resident of the nursing facility. One would certainly question the validity of the initial nursing home assessment, especially in consideration of the patient's history, when he was assessed to be independent for ambulation and activities of daily living.
The Joint Commission's National Patient Safety Goals (NPSG) for Long Term Care include the requirement to reduce the risk of falls, as it does in the acute care setting. Long Term Care's NPSG.09.02.01 requires accredited facilities to "reduce the risk of resident harm from falls" and provides the following rationale for this goal: "Falls account for a significant portion of injuries in hospitalized patients, long-term care residents, and home care recipients. In the context of the population it serves, the service it provides, and its environment of care, the organization should evaluate the resident's risks for falls and take action to reduce the risk of falling, as well as the risk of injury, should a fall occur. The evaluation could include a resident's fall history; review of medications and alcohol consumption; gait and balance screening; assessment of walking aids, assistive technologies, and protective devices; and environmental assessments." The Elements of Performance for NPSG.09.02.01 are (1) Assess the resident's risk for falls (2) Implement interventions to reduce falls based on the resident's assessed risk (3) Educate staff on the fall reduction program in time frames determined by the organization (4) Educate the resident and, as needed, the family on any individualized fall reduction strategies and (5) Evaluate the effectiveness of all fall reduction activities, including assessment, interventions, and education.
As noted, the responsibility for assessment, particularly falls risk assessment, clearly rests on the shoulders of the health care organization. There are tools, however, to assist in the assessment process. One such tool is the Morse Fall Scale, developed by Janice M. Morse in 1985 and deemed by many health care organizations as a falls risk assessment standard. The Morse Fall Scale scores the variables of history of falling, secondary diagnosis, ambulatory aid, IV or IV access, gait, and mental status; the higher the score, the higher the risk. Low-, medium-, or high-risk prevention interventions are then to be implemented in correlation with the score.
The assessment issues in this case were compounded by the nursing facility fire, but they still did not excuse the organization from initially performing an adequate and appropriate assessment. It is sad and frightening to think this resident was left to his own devices to evacuate the facility and that one nursing assistant was responsible for 24 residents. The "no complaint of pain" used as a determination of a non-fracture was frivolous on the part of the defendant. Nonetheless, a second falls assessment was required after the first fall in the nursing facility, which may have helped to prevent or reduce the risk of a second fall during the fire and the resident's subsequent health complications and death. A verdict for the plaintiff was not a surprise in this case.