Legal Review & Commentary

Alleged failure to monitor high fall risk leads to brain injury, $500,000 settlement

By Radha V. Bachman, JD, LHRM

Buchanan Ingersoll & Rooney

Tampa, FL

and Lynn Rosenblatt, CRRN, CCM, LHRM

Healthsouth Sea Pines Rehabilitation Hospital

Melbourne, FL

News: A 66-year-old man presented to the hospital with symptoms of alcohol withdrawal. The man was placed on an IV and put in bed. The patient later attempted to get out of bed, but he fell down and struck his head on the floor. The hospital settled with the man for $500,000.

Background: A self-employed 66-year-old man presented at a local emergency department appearing to have alcohol withdrawal syndrome. He was seen by the emergency physician, who placed him on a "banana-pack IV," or an IV containing vitamins and minerals. The bags typically contain thiamine, folic acid, and 3 g of magnesium sulfate, and they usually are used to replenish nutritional deficiencies or correct a chemical imbalance in the human body. The multi-vitamin solution has a yellow color, hence the term "banana bag."

Upon receiving the IV, the man was placed in the care of the floor nurse. The nurse apparently instructed the man to remain in bed or request assistance if he needed to get up from the bed, but despite these instructions, the man attempted to get out of the bed by himself. The nurse tried to intervene, but the man fell and struck his head on the floor. Following the accident, he was diagnosed with a subdural hematoma and underwent emergency neurosurgical evacuation. The man remained in the ICU for four weeks before beginning two months of inpatient neurocognitive treatment. The man remains mildly to moderately brain damaged.

The man's appointed guardian sued the hospital for negligence. The guardian argued that the patient presented a very high fall risk and that strict fall precautions should have been employed. The plaintiff further contended that the fall precautions should have been fully communicated to the patient and his family, which was not adequately done in this case.

In its defense, the hospital argued that it was compliant at all times with the standard of care. In calculating potential damages, the plaintiff proffered evidence that the man was making about $125,000 per year and that he would have continued working as a heavy equipment broker until age 72. The hospital's experts countered that the man's abuse of alcohol would have limited his ability to work. The parties ultimately entered into a settlement in the amount of $500,000.

What this means for you: This patient had been identified as having alcohol withdrawal syndrome, which certainly alerts the staff to the probability that he would experience delirium tremens (commonly known as the DTs) to some degree.

Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe mental or nervous system changes. Symptoms most often occur within 72 hours after the last drink, but they may occur up to 10 days after the last drink. Symptoms may get worse quickly and can include body tremors as well as changes in mental function. Significant to a patient's presentation is agitation, irritability confusion, disorientation, and decreased attention span.

The patient might experience periods of delirium, hallucinations with which he or she sees or feels things that are not there, quick mood changes with restlessness, and agitation. The patient also might be overly fearful, in a stupor, and overly sensitive to noise, light, and touch. Seizure activity is also possible, but more likely within 48 hours of the last drink.

Obviously such a patient is at an extremely high risk for falls, as any of the above symptoms could induce the patient to get up unexpectedly, roll out of bed, or merely not have the cognitive ability to follow directions. Such patients are incredibility impulsive, which defies personal safety.

Instructing a patient suffering from delirium tremens to remain in bed and use a call light is in the same vein of giving such instructions to a 4-year old. They are either quickly forgotten or totally ignored. The impulses to get up for whatever reason is the driving force, not safety restraints.

Hospitals have policies that dictate a fall assessment on admission, but those policies might be limited to higher risk units and not universal across all services. While there are standardized assessment instruments, some might be irrelevant to certain classes of patients for whom falls are more likely based on the diagnosis or patient's presentation at the time the assessment is administered.

While the patient might be alert and responsive on assessment at the time of admission and score within a safety zone, in terms of fall risk, the underlying diagnosis might be of greater value in determining what safety precautions might be needed. In this case, the patient's alcoholism predisposed him to the DTs as he was being detoxified. With each successive hour without a drink, the potential for cognitive dysfunction, confusion, and agitation increased. These are all high risk areas that predispose falls.

Fall prevention strategies are varied and should be specific to the patient's cognitive presentation and behavioral indicators. For those who are alcoholics and in withdrawal, they frequently display disruptive behaviors that are poorly controlled. The nursing staff should be trained to expect and anticipate such behaviors and the inherent risks.

It is to be expected that the patient will try to get up. Balance is also a problem for drinkers and the root of the expression "falling down drunk." Patients who are delirious and have visual hallucinations will exhibit agitation and perhaps fall out of bed.

Researchers and medical professionals already know that chronic, excessive alcohol consumption causes cognitive and motor deficits. Operating as a central nervous system depressant, alcohol produces a dose-dependent decrease in cognitive and motor functioning, which is another indicator of potential falls. It is also an indication that personal safety must extend beyond the patient to the family, as they will be more compliant than one could ever hope the patient to be.

For those who are alcoholics in withdrawal, they rarely have family with them and usually go it alone. Or if the family is available, there are frequently emotional barriers to witnessing the withdrawal symptoms, and they stay remotely attached but nonetheless supportive.

While the plaintiff contended that the fall precautions should have been fully communicated to the patient and his family, which was not adequately done in this case, any instructions given were not going to be effective if not coupled with strong preventive measures. In this case, the patient should have been under close observation at all times to ensure that should he attempt to get out of bed, someone could immediately intervene. Documentation should include the number and frequency of attempts to get up, so that increased activity is noted and so that measures can be taken promptly to address escalating behaviors. A bed alarm should be in place. All four rails should be in the up position, with nurses ensuring that the patient is given the opportunity to get up to the bathroom as needed.

The Joint Commission states that four rails constitute a restraint, so an order must be obtained, and the patient must be observed at scheduled intervals. While this situation requires manpower, it is certainly preferable to a serious injury fall and the resulting liability.

Hospitals have fall prevention policies, but risk managers need to question whether those policies are sufficient for every population group and investigate how those policies are disseminated across all services and staff. In this case, it does not appear that anything was done to anticipate that the patient would not act as a coherent responsible adult.

Reference:

Superior Court of California, Confidential.