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Summary: As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes. When a family member is placed in a facility, a certain standard of care is expected. In this case, a resident was injured repeatedly while under their care. When the patient died a few days after being "dropped" the family sued.
The patient was a 95 year old woman who was placed in a Missouri nursing home when the family was no longer able to care for her needs.
"Approximately 1.5 million people live in the nation's 17,000 nursing care facilities. . .The typical nursing home resident is a woman in her 80s displaying a mild form of memory loss and dementia. Although physically healthy for a woman her age, she needs help with approximately 4 of 5 activities of daily living (eating, transferring, toiletting, dressing, and bathing)."2
During her admission the patient would sustain multiple injuries over the course of her stay. In 1993, on two occasions, the patient's legs were broken with fractures diagnosed. Each time the patient was transferred to the hospital for treatment and then returned to the nursing home.
Each time the documentation would show that the family had been "made aware." This was reflected in incident reports that had been filed. The incident reports did not specify which family members had been notified.
A third injury took place in 1995 when the patient was being transferred from her bed. Documentation of the incident stated that the patient had been "dropped" during a transfer. The charted notes documented that a head injury was sustained and that family members were notified.
The patient was again transferred to the hospital and was evaluated in the Emergency Department. Interestingly, when examined by a physician, the day after the incident, the physician stated that there was no evidence of head injury. Five days following this examination, the patient died.
The family would sue the nursing home. They would allege that standards of care had not been met. They would accuse the nursing home of rendering negligent care.
It is no secret that nursing home abuse occurs. It can take many different forms and have devastating consequences on residents and their families.
"The United States Department of Health and Human Services researchers identified seven categories of abuse. Ninety-five percent of those surveyed said they felt that all seven are problems for nursing home residents:
Physical abuse --infliction of physical pain or injury.
Misuse of restraints --chemical or physical control of a resident beyond physician's order or outside accepted medical practice.
Verbal/emotional abuse --infliction of mental or emotional suffering.
Physical neglect --disregard for the necessities of daily living.
Medical neglect --lack of care for existing medical problems.
Verbal/emotional neglect --creating situations harmful to the resident's self-esteem.
Personal property abuse --illegal or improper use of a resident's property for personal gain."3
The basis of the family's lawsuit centered on the assumption that a certain standard of care, and a "duty" is owed to nursing home residents. This duty it was assumed, included safe living conditions, freedom from harm and timely medical treatment. They alleged that these standards had not been observed by the nursing home.
In the initial trial, a review of the charting and documentation showed that in each "incident," facility protocols had been followed. Upon discovery of the injuries, medical treatment and family notification had been provided.
The Defense moved to have the charges dismissed. The court agreed.
The family appealed.
Questions to be answered.
1. Was there clear evidence of either neglect or abuse on the part of the nursing home staff in either of the three documented incidents of injury?
2. Had standards of care been met in regard to treating an injured patient and providing safe and reasonable care.
Chiefly due to the timely documentation of the incidents, the records were used to demonstrate adequate care being given.
The family's lawsuit chiefly targeted the "handling" of the incidents rather than the "cause" of injury. The documented interventions and notifications on the part of the nursing staff provided sufficient proof that standards were upheld.
It is common knowledge that documented nurses' notes and the medical chart are legal records. They should be written and treated at all times as if a jury will later examine them.
Had the incident not been documented as thoroughly or had incident reports not been filled out, it might have been a different story. It was the clear and concise charting of the nursing homes staff's handling of the incidents that saved the facility from a potentially costly lawsuit and trial.
This was particularly evident when the family accused the nursing home staff of "failure to notify" the family members. As long as efforts were documented in the notes to notify the family, the facility was covered.
It is a bit strange that the specifics as to "who" was notified was not included in the chart. Under a different set of opinions, this could easily be interpreted as a "red flag." In this case it was not.
This documentation of "notification" could have been seen as the nursing home staff charting to cover themselves regardless of whether a family member had been contacted.
To minimize suspicions of impropriety it is suggested that when a family member is contacted, the name and phone number also be documented. All evidence is subject to interpretation. This can be applied to physician notification as well.
When a patient has an attending, consulting physicians and residents responsible for their care, "MD made aware" leaves much room for debate as to who was notified. If the name of the physician is noted, the guesswork is removed and accountability easier to establish.
What was not addressed in this case was the nature of the "accidental" injuries. It is not difficult to imagine a 95-year-old patient falling as she tries to get out of bed. It is common for patients to fall on their way to or from the bathroom. The pertinent question is "could the injuries have been avoided."
It is clear from published studies that indeed many can be.
""We found that neither complaint investigations nor enforcement practices are being used effectively to assure adequate care for Nursing Homes residents and the prevention of nursing home abuse and neglect. As a result, allegations or incidents of serious problems, such as inadequate prevention of pressure sores, failure to prevent accidents, and failure to assess residents' needs and provide appropriate care, often go uninvestigated and uncorrected."4
Lawsuits against nursing homes are common and on the rise. If you are working in a nursing home, you need to be aware that you are responsible for documenting adequate care. You are equally responsible for prevention. If a dangerous condition or "accident waiting to happen" is identified, steps must be taken and documented to correct it.
If a patient is at risk for falling they may refuse to call for assistance. If they try to get out of bed anyway, it should be documented that the patient was instructed to "call for assistance," and did not.
If a patient is clearly a danger to himself or herself and others, restraints may be indicated. The family or the physician may refuse to allow or write an order for them. The nurse must document that the need for them was communicated, to whom and the response.
Even with adequate care being given accidents can happen with legal consequences. Nursing homes are currently the focus of intense governmental supervision and regulation. The effectiveness of the regulation is debatable. There are many that feel that the only "solution" to correcting problems are legal actions against nursing homes.
If this approach is to be paralleled to eliminating medical malpractice, a solution may be a long way off. What can be anticipated is increased pressure from the government, from consumers and the courts. This will result in increased litigation and increased pressure on nursing home staff and facilities. Each member of the nursing staff would be wise to document carefully daily care and especially incidents that result in injury.
Related Case Studies:
June 13, 1999: Felony Child Abuse Conviction, Made Possible Thanks to Nurse's Documentation.
State v. Gillard, 936 S.W. 2d 194 - MO (1999).
http://www.nursefriendly.com/nursing/clinical.cases/061399.htmJune 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Gordon v. Lewiston Hospital, 714 A.2d 539 - PA (1998)
http://www.nursefriendly.com/nursing/clinical.cases/060699.htmMay 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)
http://www.nursefriendly.com/nursing/clinical.cases/053099.htmRelated Link Sections:
Abuse:
http://www.nursefriendly.com/nursing/directpatientcare/abuse.htmClinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htmEmergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.htmlEthics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htmHead Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htmMechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htmNursing Homes, Long Term Care Links:
http://www.nursefriendly.com/nursing/nursing.homes.long.term.care.htm
Sources:
1. 40 RRNL 1 (June 1999)
2. American Health Care Association. September 1998. Profile: Nursing Facility Resident: Retrieved June 27, 1999 from the World Wide Web: http://www.ahca.org/secure/nfres.htm
3. Seniors-Site. No date given. Nursing Home Abuses to Senior Citizens. Retrieved June 27, 1999 from the World Wide Web: http://seniors-site.com/nursing/abuses.html
4. United States Senate. March '99. Excerpts from Committee On Aging Hearings. Retrieved June 27, 1999 from the World Wide Web: http://www.jeffdanger.com/
The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/062799.htmSend comments and mail to Andrew Lopez, RN Created on Saturday May 23, 1999
Last updated by Andrew Lopez, RN on Saturday, September 17, 2011
Tuesday, December 6, 2011
Elderly Patient Repeatedly Injured In Nursing Home "Accidents." Negligence, Coincidence or Abuse? #nursefriendly #nursecasestudy #elderly #geriatrics
Monday, November 21, 2011
Patient Left Unrestrained, #Patient Injured. #Nurses Judgement Call, #nursing #malpractice #nursefriendly #epatient #negligence
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Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Attorneys, Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material.
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Please send a blank e-mail to: clinicalnursingcases-subscribe@topica.comSummary: The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued.
The patient was involved in a motor vehicle accident. A head injury was suffered leaving him in a state of confusion and prone to agitation.
"Each year, an estimated 2 million people sustain a head injury. About 500,000 to 750,000 head injuries each year are severe enough to require hospitalization. Head injury is most common among males between the ages of 15-24, but can strike, unexpectedly, at any age. Many head injuries are mild, and symptoms usually disappear over time with proper attention. Others are more severe and may result in permanent disability." 2
Following the head injury, the patient was visibly confused and frequently became agitated. During the course of his admission, an order for "soft" wrist restraints was obtained and implemented to protect the patient from injury related to mental status (personality) changes.
"Personality Changes-Apathy and decreased motivation. Emotional lability, irritability, depression. Disinhibition which may result in temper flare-ups, aggression, cursing, lowered frustration tolerance, and inappropriate sexual behavior."2
On the day of the incident, the nurse on duty had assessed the patient. In her professional opinion restraints were not needed.
"What Is Restraint?
"Restraint" is physical force, mechanical devices, chemicals, seclusion, or any other means which unreasonably limit freedom of movement. hospital staff may use four types of restraint to restrict patients who are acting, or threatening to act, in a violent way towards themselves or others.
Physical restraint--holding a patient for over five minutes in order to prevent freedom of movement.
Mechanical restraint--using a device, such as 4-point or full sheet restraint, to restrict a patient's movement (excludes devices prescribed for medical purposes).
Chemical restraint--medicating a patient against her will for the purpose of restraint rather than treatment.
Seclusion--placing a patient alone in a room so that she cannot see or speak with patients or staff and the patient cannot leave or believes she cannot leave."3
She based this decision on her observation of the patient's mental, physical state and level of consciousness. It is common procedure and protocol in facilities for patient's to be released from restraints when the danger of violence is felt to have passed.
"How Long May Restraint Continue?
When an emergency no longer exists, the patient should be released. Thus, staff should release a patient who, upon examination, appears calm. The total time which a patient may be restrained is limited:"3
Later in the shift, the same nurse was helping the patient get up. In the course of this maneuver, the patient fell and claimed that an injury was sustained.
A lawsuit would be filed against the facility alleging negligence on the part of the nurse. The patient contended that the removal of the restraints breached standards of care.
In the initial trial, the jury was instructed to view the nurse's role as an "error in judgement." Based on this and on testimony on the proper use of restraints, standards of care, the court found for the facility.
The patient appealed.
Questions to be answered:
1. Was the nurse in error to remove the restraints from a patient when she felt they were no longer needed.
2. Did the removal of the restraints directly contribute to the "injury" that the patient claimed to sustain?
3. Were the standards of care governing restraint use adequately maintained?
The plaintiff's arguments sought to convince the jury that poor judgement was exercised by the nurse. It was contended that removal of the restraints and ambulation of the patient put him in harm's way.
With the patient assessed to be calm, the purpose of the restraints, "to prevent the patient from harming himself or others," had been achieved.
The purpose of the restraints had not been to "keep the patient from falling out of bed." The removal of the restraints then, could not be deemed as negligent. There was no duty of care breached in allowing the calm patient to remain unrestrained.
The order was in place to ambulate the patient when stable. In the nurse's opinion, the patient was ready. Another nurse may not have agreed with her actions. The patient under a different nurse's care might have been kept in restraints. A nurse could have "held off" on the order to ambulate.
There was no causative relationship between removing the restraints and the patient's fall. In carrying out orders for ambulation, the nurse was providing proper nursing care.
It's not difficult to picture a lone nurse with an unsteady patient losing control and having the patient slip away. Would this be a breach of duty owed to the patient?
One could argue that the nurse had no business trying to move a patient by herself. One might also observe the staffing patterns at the time and realize the nurse was doing "the best she could."
The decision to remove the restraints was clearly a nursing decision. Often the decision to use them in the first place lies with the nurse too.
This illustrates the leeway and discretion given nurses when carrying out physician's orders. It also shows the typical catch 22 situation some nurses may find themselves in regarding restraint use.
"Historically, conventional wisdom supported using physical restraints, including bed side rails, to "protect and safeguard" residents. Ironically, little documented evidence exists that restraints prevent falls and risk of injury from falls. Clinical studies demonstrate that restraints, conversely, in some instances, precipitate or exacerbate fall risk."4
Both nurses in the above situation would be acting within their scope of practice. Each would be adhering to standards of care.
For the plaintiff to have a case, it would need to proven that either the removal of the restraints or the ambulation of the patient was premature.
This was clearly not the case. The actions of the nurse were in good faith and exercised reasonable concern for the well being of the patient. The fact that the patient suffered a fall is unfortunate, and reasonably unforseeable.
It can be compared to the actions of a physician when dealing with an acute patient. Depending on which course of treatment that physician chooses, the patient might or might not have a favorable outcome.
In either case, as long as the physician exercises reasonable judgement based on established principles of practice, a finding of negligence is unlikely.
It has been well established that Medicine is not an exact science. Outcomes are not guaranteed when prescribing courses of treatment.
They are the result of standard medical practices and individual patient responses. These responses are not always predictable. Basically, the caregiver can only hope for the best.
The same principle applies to Nursing care. Regardless of how accurate assessments are and how diligently orders are carried out, patients may or may not experience favorable outcomes.
When outcomes are unfavorable, it is the constitutional right of the patient or patient's estate to sue anyone felt to be involved.
The court reviewed the facts of the case and a nursing expert's testimony on restraint use. The appeals court agreed that standards of care had been maintained.
There exists today intense pressure from family members, governmental agencies and regulatory agencies to limit restraint use to "only when absolutely necessary." As soon as they are put in use, the plan of care must include provisions for their removal.
Link Sections:
Head Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htmEthics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htmMechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...Medical Legal Consulting Nurse Entrepreneurs
http://www.nursefriendly.com/nursing/ymedlegal.htmSources:
1. RRNL 2 (July 1997)
2. Family Caregivers Alliance Clearinghouse. Revised November 1996. Fact Sheet: Head Injury. Retrieved May 30, 1999 from the World Wide Web: http://www.caregiver.org/factsheets/head_injury.html
3. Mental Health Legal Advisors Committee. No date given. Your Rights in Hospitals Regarding Restraining and Seclusion. Retrieved May 30, 1999 from the World Wide Web: http://www.psychiatry.com/mhlac/basicrights/restraintandseclusion.html
4. Braun, Julie A. & Quish, Clare J. 11/10/98. Illinois Institute for Continuing Legal Education. Physical Restraints And Fall-Related Injuries. Retrieved May 30, 1999 from the World Wide Web: http://www.iicle.com/articles/braun11_10_98b.html
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Tuesday, March 29, 2011
Arch Intern Med -- Abstract: Patient Education to Prevent Falls Among Older Hospital Inpatients: A Randomized Controlled Trial, March 28, 2011, Haines et al. 171 (6): 516
Arch Intern Med. 2011;171(6):516-524. doi:10.1001/archinternmed.2010.444
Background Falls are a common adverse event during hospitalization of older adults, and few interventions have been shown to prevent them.
Methods This study was a 3-group randomized trial to evaluate the efficacy of 2 forms of multimedia patient education compared with usual care for the prevention of in-hospital falls. Older hospital patients (n = 1206) admitted to a mixture of acute (orthopedic, respiratory, and medical) and subacute (geriatric and neurorehabilitation) hospital wards at 2 Australian hospitals were recruited between January 2008 and April 2009. The interventions were a multimedia patient education program based on the health-belief model combined with trained health professional follow-up (complete program), multi-media patient education materials alone (materials only), and usual care (control). Falls data were collected by blinded research assistants by reviewing hospital incident reports, hand searching medical records, and conducting weekly patient interviews.
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Wednesday, March 2, 2011
FRAX, Fracture Probability Tool
Welcome to FRAX®
The FRAX® tool has been developed by WHO to evaluate fracture risk of patients. It is based on individual patient models that integrate the risks associated with clinical risk factors as well as bone mineral density (BMD) at the femoral neck.
The FRAX® models have been developed from studying population-based cohorts from Europe, North America, Asia and Australia. In their most sophisticated form, the FRAX® tool is computer-driven and is available on this site. Several simplified paper versions, based on the number of risk factors are also available, and can be downloaded for office use.
The FRAX® algorithms give the 10-year probability of fracture. The output is a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).
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Monday, November 15, 2010
JAMA -- Abstract: Fall Prevention in Acute Care Hospitals: A Randomized Trial, November 3, 2010, Dykes et al. 304 (17): 1912
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Fall Prevention in Acute Care HospitalsA Randomized Trial
Patricia C. Dykes, RN, DNSc; Diane L. Carroll, RN, PhD, BC; Ann Hurley, RN, DNSc; Stuart Lipsitz, ScD; Angela Benoit, BComm; Frank Chang, MSE; Seth Meltzer; Ruslana Tsurikova, MSc, MA; Lyubov Zuyov, MA; Blackford Middleton, MD, MPH, MSc
JAMA. 2010;304(17):1912-1918. doi:10.1001/jama.2010.1567
Context Falls cause injury and death for persons of all ages, but risk of falls increases markedly with age. Hospitalization further increases risk, yet no evidence exists to support short-stay hospital-based fall prevention strategies to reduce patient falls.
Objective To investigate whether a fall prevention tool kit (FPTK) using health information technology (HIT) decreases patient falls in hospitals.
Design, Setting, and Patients Cluster randomized study conducted January 1, 2009, through June 30, 2009, comparing patient fall rates in 4 urban US hospitals in units that received usual care (4 units and 5104 patients) or the intervention (4 units and 5160 patients).
Intervention The FPTK integrated existing communication and workflow patterns into the HIT application. Based on a valid fall risk assessment scale completed by a nurse, the FPTK software tailored fall prevention interventions to address patients' specific determinants of fall risk. The FPTK produced bed posters composed of brief text with an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders.
Main Outcome Measures The primary outcome was patient falls per 1000 patient-days adjusted for site and patient care unit. A secondary outcome was fall-related injuries.
Results During the 6-month intervention period, the number of patients with falls differed between control (n = 87) and intervention (n = 67) units (P=.02). Site-adjusted fall rates were significantly higher in control units (4.18 [95% confidence interval {CI}, 3.45-5.06] per 1000 patient-days) than in intervention units (3.15 [95% CI, 2.54-3.90] per 1000 patient-days; P = .04). The FPTK was found to be particularly effective with patients aged 65 years or older (adjusted rate difference, 2.08 [95% CI, 0.61-3.56] per 1000 patient-days; P = .003). No significant effect was noted in fall-related injuries.
Conclusion The use of a fall prevention tool kit in hospital units compared with usual care significantly reduced rate of falls.
Trial Registration clinicaltrials.gov Identifier: NCT00675935
Author Affiliations: Partners HealthCare System (Drs Dykes and Middleton, Ms Benoit, and Messrs Chang and Meltzer), Brigham and Women's Hospital (Drs Dykes, Hurley, Lipsitz, and Middleton, and Ms Tsurikova), Harvard Medical School (Drs Dykes, Lipsitz, and Middleton), and Massachusetts General Hospital (Dr Carroll and Ms Zuyov), Boston.
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Themes of Aging: Preserving Function, Improving Care
Winker
JAMA 2010;304:1954-1955.
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