Legal Review & Commentary: Fall and fractures lead to a $240,000 settlement

News: After being admitted to a hospital for hip pain, a 69-year-old woman was allowed to walk about unassisted. Days later, X-rays showed she had a hip fracture, which was operated on. She was transferred to the nursing home next door to recuperate and be rehabilitated.

On the seventh day of her stay, she fell and re-fractured her hip. This time, the hip repair included a total replacement. The patient brought suit against the hospital, nursing home, and her attending physicians. The cases against the physicians were later dropped; the nursing home and hospital settled for $240,000.

Background: The 69-year-old woman, who had a history of schizophrenia, was admitted to the hospital with hip pain. Radiological examination, including an MRI, failed to indicate a cause and the patient was allowed to walk without assistance. A few days later, she was walking and heard a crack. X-rays showed she had a fractured hip. She underwent open reduction and internal fixation for the fracture.

Following the surgery, she became extremely agitated. Her schizophrenia was no longer being controlled with psychotropic medications. It is not known if she was placed back on any medications. She was transferred to a nursing home adjacent to the hospital, and her transfer papers clearly detailed her high risk of falling with any ambulation.

Once admitted to the nursing home, the admitting nurse’s chart note indicated that the patient was a high risk for falls, but the nurse failed to complete forms instructing the nursing assistants on how to monitor and care for the patient. No precautions for the avoidance of falls were taken. Seven days later, the patient tried to get out of her wheelchair and fell over, re-fracturing her hip. She was re-admitted to the hospital and told she needed a total hip replacement.

The doctor who performed the first surgery admitted that his repair work was obliterated and could not be more simply repaired due to the second fall.

The patient brought suit against the nursing home, hospital, and attending physicians. She argued that the nursing home should have provided a variety of safety devices to decrease the chance of falls, including nontipping devices that could have been easily added to her wheelchair. It was claimed that the nursing home should have lowered her bed to the floor and modified her toilet schedules so that she would have less need to get up.

The nursing home, as defendant, contended that the patient was an unreliable witness and unable to testify due to her schizophrenia and confusion. But this could just as easily have been used to show that the nursing home should have provided additional care to ensure her safety and security and address known medical conditions. The hospital contended that the injury occurred in the nursing home and that it bore no responsibility for what happened there.

Actions against the physicians were discontinued, with no payment by either. The nursing home and hospital eventually settled with the plaintiff for $240,000, with the nursing home picking up the bulk of the tab, $225,000, leaving the hospital responsible for $15,000.

What this means to you: This case certainly speaks to the necessity of accurate assessment of the patient both on admission and continuing over the length of stay, no matter if the patient is in the facility a short time or indefinitely. A patient’s presentation on day one can be greatly different on day five or day 31.

A formal falls assessment that covers a multitude of indicators over time is the obvious first step in establishing a patient’s baseline.

"A complete medical history goes a long way to provide a basis for the falls prevention program that should be individualized for that particular patient. Not only is the patient’s past fall history significant, but an overview of his/her functional abilities and current state of health is essential. Family input at the time the patient is admitted is also highly desirable in developing an accurate profile of the risks pertinent to the patient," notes Lynn Rosenblatt, CRRN, LHRM, risk manager at HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL.

Questions raised by this scenario includes: Does the patient suffer from hypertension, a seizure disorder, diabetes, hypoglycemia, or syncope? What type of medications does the patient take? Should any significant medical history be addressed? Does the patient present with dementia? Can the patient follow directions? Is the patient’s memory intact? Is the patient’s orientation consistent? What is the state of the patient’s vision and hearing? Is the patient aware of limitations?

The admitting nurse should carefully assess the patient’s mobility as a result of surgery or other previous disabling conditions. Are there any impairment to gait and mobility? Is the patient able to stand for transfers? How much assistance does the patient need? Is the patient fully continent? Can the patient be trusted in the bathroom alone? Can the patient ambulate and how far? What assistive devices are necessary?

"Assessing all of these facts, at the time of admission, provides a basis on which the nurse can formulate an individualized fall prevention plan for the patient. Had the nurse noted the patient’s history of schizophrenia, she logically should have addressed the fact that the patient was not receiving medications usually indicated for a psychiatric condition. This information would have also alerted the nurse to possible changes in the patient’s behavior over time," Rosenblatt says.

The patient’s mobility status would have provided the nurse with reference points as to when the patient may be at highest risk for fall over the course of the day. The development of sound policies related to toileting patients, safe transfers, side rails and bed-height positioning, and use of assisted devices are paramount to a safe environment.

Once the nurse has formulated an accurate assessment of the patient’s medical condition and the factors that contribute to falling, a prevention program for that particular patient can be implemented using existing policy and procedures.

"In this case, it appears that the nurse merely noted the patient to be at risk but did not address that risk appropriately. This highlights the value of a falls risk-flowsheet that not only identifies an individual patient’s own risk factors, but provides a mechanism to develop a plan that avoids placing the patient in an increased-risk situation," says Rosenblatt.

"Then the plan must be communicated to the assigned caregivers. This speaks to communication tools used between the individual staff members across all shifts. Team rounds or posting the risk-prevention plan at the bedside provide a means to alert those caring for the patient to the particulars of the safety protocols for that patient. The credibility of the plan is lost if it does not allow for reassessment on a continuing basis. In this case, the patient’s mental status was a factor codependent on the fact that she may not have been receiving her usual psychotropic medications. Over seven days, there may have been behavioral factors that were either overlooked, not documented, or both," adds Rosenblatt.

Obvious changes in cognitive status, unusual behaviors, and restlessness are all indicators of deterioration in mental acuity. They also place the patient at higher risk for falls. Agitated patients are particularly unpredictable in terms of safety concerns. The initial plan must be modified as often as necessary based on patient observation. It should be time sensitive as to day, evening, and night shifts.

Techniques for preventing falls may require modification as the patient’s condition improves. Bed rails and bed height are preventative measures at bedtime or for the bed-bound patient. Greater mobility may equate to more opportunity for a fall. Wheelchair-bound patients are likely to attempt to stand particularly if they are unable to comprehend their full limitations.

"Seat alarms can be helpful if the patient’s ognition is such that the sound provides a recognizable signal to the patient, but they are worthless if they only signal the staff that the patient is on the floor. Anti-tipper devices also have limitations. If a patient is prone to leaning forward or tipping back, than an anti-tipping device may provide some stabilization, but if the patient stands or is extremely heavy, the device will be of little reliability," Rosenblatt says.

"Patients using walkers and other gait aides are also at higher risks for falls. These facts demonstrate the need to accurately assess the patient together with the prevention plan that was developed, and not only to match that plan to the individual but to the environment on the unit and particular activities that are part of the normal day," add Rosenblatt.

"The admitting nurse failed to follow policy on completion of forms related to the patient’s care and monitoring requirements. Since a mechanism did not exist for daily review of the patient’s risk potential, the nursing assistants were unaware of their heightened responsibility toward this patient. They had no insight into her potential for falls or unpredictable behaviors as a result of her previous psychiatric history."

While the Health Insurance Portability and Accountability Act restricts the type of information that can be visibly displayed and widely communicated, the key factors in an individual patient-risk prevention plan is essential to maintenance of a safe care environment and oversight of the patient. Policy development and communication procedures that accomplish that end would have possibly prevented this suit.

"Insufficient information is provided to access any legal concerns related to the acute care admission. It would appear that the nursing home was operated by the hospital as a distinct entity. If that was not the case and the nursing home was in fact operated under the same governance as the hospital, the hospital would have shouldered the entire settlement. The payment of $15,000 in such a large verdict indicates more a nuisance level of settlement.’ This is another area of concern for providers, as once a case is brought, it is frequently difficult to get out without some payment even in the absence of liability," opines Rosenblatt.


• Queens County (NY) Supreme Court, Index No. 12275/99.