News: In late 2014, an elderly man went to a hospital for the implantation of a pacemaker. He was given zolpidem to help him sleep; however, it was ineffective, and a nurse was required to help him into a chair beside his bed. The medication made him drowsy and lose motor control, and he fell out of his chair.

The man suffered a laceration on his ear, and later scans indicated he also suffered a subdural hematoma. He was later transferred to hospice care, where his condition deteriorated and he eventually passed away. His wife and daughter brought suit against the hospital, alleging that it was negligent in monitoring him. The jury found in favor of the plaintiffs and awarded them $3 million for the wrongful death.

Background: On Dec. 26, 2014, an 84-year-old man underwent a procedure for pacemaker implantation. Shortly before midnight on Jan. 2, 2015, the man was administered zolpidem to help him sleep while recuperating from the surgery. A few hours later, at approximately 1:30 a.m., a nurse moved the man to a chair beside his bed, as he was still unable to sleep. At some point that night, the man fell out of the chair and hit his head, suffering a laceration to his right ear that required stitches.

After the injury, a CT scan showed a subdural hematoma and, in the days following, the man’s brain swelled and bled. The hematoma caused brain tissue to push onto his spinal cord, rendering him paralyzed on the left side of his body.

On Jan. 7, a craniotomy was performed to relieve the swelling in the patient’s brain, and he remained intubated until Jan.10. His family reported that he complained of head pain and exhibited outward signs of discomfort. On Jan. 20, the patient was transferred to hospice care where he died two days later.

The patient’s wife and his daughter sued the hospital and its parent company, alleging a failure to monitor. The plaintiffs claimed that the patient, who had exhibited signs of memory impairment and was deemed a high fall risk, was negligently placed in a chair without any fall precautions, such as an alarm. They further contended that the patient attempted to get out of the chair without assistance when he fell, likely in attempt to get back into bed or to use a urinal on a side table.

The plaintiffs’ nursing expert testified that the man experienced forgetfulness and short-term memory impairment prior to the incident. The expert further testified that this was documented by the nurse on duty at least 16 times in the nursing records. According to the expert, zolpidem amplified his memory issues and impaired his motor functions, thus increasing his fall risk. The nursing expert did not fault the hospital for administering the medication, but argued that the chair should have had an alarm, since he was prone to falling. An alternative was to have him sit next to the nurse’s station in the hall, so that the nurse could have monitored him while she worked at her computer.

The defendant argued that chair alarms do not reduce the risk of falls, and the patient did not need one. The defense also testified that older patients commonly fall and not every fall is preventable, nor does every fall cause serious injury. Moreover, an alarm can unnecessarily restrict the movements or choice of older patients who understand instructions and the need to ask for assistance. The hospital’s geriatric medicine expert stated that the zolpidem did not affect the patient’s motor function or overall condition, and that it did not contribute to his fall.

The jury deliberated for four hours after a four-day trial, finding in favor of the plaintiffs. The jury awarded a total of $3 million for wrongful death.

What this means to you: Many elderly patients die from fall-related injuries each year. Chair alarms came into use in response to the ban on physical restraints in the 1990s. They are pressure-sensitive pads that are placed on chairs and sound an alarm when a patient shifts his or her weight, indicating they are getting up. Research has suggested that these alarms may pose a risk to patient safety because their use can result in staff complacency. By the time nurses respond to the alarm, patients likely have already fallen to the floor, rendering the alarm useless for its intended fall prevention purpose.

Some medical facilities have begun phasing out alarms and other fall prevention methods to prioritize attentive care. These facilities focus on learning patient routines and accommodating patients who wish to move about freely. They also focus on changing bathroom schedules, rearranging rooms, and providing more mental stimulation to patients to help them regain autonomy and dignity.

While these changes are preferable for overall patient well-being, there is concern that they will inflate the number of falls, exposing care facilities to liability — especially, like in this case, where an alarm may have prevented the fall or minimized the injuries.

Other medical care facilities strike a balance by moving to discreet sensors that alert nursing staff of the patient’s movement without causing embarrassment or other negative effects. These sensors communicate with nursing staff directly and alert them of the need to assist the patient.

Other fall prevention methods include lowering beds when patients sleep, placing fall mats, or softening flooring. Hospitals should train staff to actively search out hazards that could increase fall risks and injuries, such as power cords, boxes, loose rugs, loose floorboards, spilled liquids, and clothing. More lighting can help prevent falls, including nightlights in bathrooms.

Medical professionals also should be keenly aware of fall risk factors, including a history of falls, decreased strength, gait or visual impairment, psychoactive medication use, dizziness, low body mass index, cognitive impairment, arthritis, and undertreated pain.

In this particular case, the injury that caused the patient’s death, a subdural hematoma, is characterized by a collection of blood between the dura mater of the brain and the surface of the brain. This bleeding fills the brain area quickly, compressing brain tissue, and is among the deadliest head injuries. The most common cause of subdural hematoma is severe head trauma.

The symptoms depend on the location and size of the hematoma and can include confused or slurred speech, balance issues, trouble walking, headache, lack of energy, seizures, nausea or vomiting, and vision problems.

Subdural hematoma typically is diagnosed via a head CT or MRI, and is often treated through a craniotomy or medications such as diuretics and corticosteroids to reduce swelling, and anti-seizure medications. Subdural hematoma is an emergency condition that requires prompt treatment. In the event of a fall, medical professionals must be cautious for any resulting emergent conditions — and the failure to do so may constitute medical malpractice.

Injury-causing falls are not limited to the elderly; younger patients are also at risk because they do not realize the limitations on mobility caused by surgical procedures and drugs, including antihypertensives, sedatives, hypnotics, analgesics, and psychotropics. These drugs have additional effects on the elderly, who metabolize them at a variable rate, making it difficult to determine when their effects will subside. Zolpidem is known to cause sleepwalking in some cases and should be used with caution, as should all medications given to seniors.

Patient falls occur in every healthcare setting, and there is no way any facility can prevent all of them. All patients who fall should be carefully assessed for occult injuries, especially if there are external bumps, bruises, or broken skin with bleeding. X-rays and scans should be done without hesitation, even if only to confirm that no injury occurred.

Of concern in this case is the delay to intervene once the patient fall was discovered. The fact that there was a laceration to the ear means that the side of his head most likely hit the floor. A CT scan should have been ordered that night, and if negative, repeated in four hours. Any evidence of a bleed should have been addressed medically or surgically on an emergent basis. In this case, the craniotomy was performed five days later, by which time the harm had already occurred.

REFERENCE

Decided on April 6, 2018, in the Delaware County Court of Common Pleas; case number 2016-6622.