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Summary: When a nurse accepts report and responsibility for the care
of a patient a duty to the patient is also accepted. This duty is to provide
a reasonable standard of care as defined by the Nurse Practice Act of the
individual state and the facility Policy & Procedures. In this case, a post-op
abdominal aneurysm repair patient was injured after falling from his bed to
the floor. When a lawsuit was filed the court initially mistook expert
testimony to imply the role of the nurse includes a guarantee of safety.
The patient was admitted for the surgical repair of abdominal aneurysm.
This is a weakening of the walls of the major artery supplying
blood from the heart to the abdomen and lower extremities. When this
occurs the vessel widens and there is a risk of rupture and rapid death from
internal hemorrhage. Once detected, physical examinations/assessments by
a Physician and Radiologic studies are performed to determine the extent of
the disease. Based on the findings, surgical repair may be indicated.
"What is an aneurysm and what causes it? An aneurysm is a balloon-like
swelling of the aorta. This is the main artery located in the middle of the
abdomen which transports blood down from the heart to the pelvis and to
the legs. Most commonly, the area of the aorta that is affected is the part
just below where the renal arteries going to the kidneys take off. The cause
of this balloon-like swelling is quite complex. Atherosclerosis certainly
co-exists with abdominal aortic aneurysms, but it is now thought to be
more of a predisposing factor rather than a single instigator of abdominal
aneurysms."2
In this case, the surgery was indicated and performed. The patient tolerated
the procedure well and was transferred to the Surgical Intensive Care Unit
(SICU). On the second day of recovery, the patient would fall from his bed.
A head injury was noted and the patient would die soon after. It was
alleged that he died as a direct result of the fall and resulting head injury.
"STATISTICS ABOUT FALLS
Every year in the United States, over $7 billion is spent on the treatment and
rehabilitation of people who are injured from falls.
Falls exceed automobile accidents as the number one cause of accidental death
for persons over 75.
National averages indicate that annually, acute care general care hospitals
experience approximately 1,000,000 fall occurrences, or about 1.5 per bed,
per year.
Thirty percent of hospital falls will result in injuries, including 5% serious
trauma such as hip fractures.
Thus, there are about 52,500 serious injury falls per year in U.S. hospitals.
Typically in acute care general hospitals, occupancy by high fall risk
patients exceeds 50% of daily census (i.e. patients are over 65 years of
age, are taking multiple medications and have one or more indications
for mobility restriction, such as muscle weakness, impaired vision, etc.)
hospitals typically incur $15,000 - $30,000 additional therapy cost per
serious inpatient fall resulting in trauma.
For example, for 100 beds, if there are 150 head per year and 5% are
serious and these cost an average of $22,500, the total cost burden is
$168,750. This equals $1687.50 of averaged cost for every bed in a
hospital."3
The estate of the patient sued the
hospital claiming that applicable
standards of care concerning patient safety had not been observed.
The plaintiff produced expert Nursing testimony regarding the
applicable standards.
There is little argument that this 74-year-old, two day post-operative
male patient was indeed a high risk for a fall.
"Factors that contribute to head in older persons are physiological
(for example, decreased strength and vision), psychological (confusion),
social (maintaining independence), and environmental (absence of handrails
or inadequate lighting). Typically the factors that cause the fall are multiple
and interact with each other."4
Issues addressed were the frequency of patient observation, the presence of
side-rails in an post-operative patient, what medications was the patient under
the influence of at the time (would they warrant closer monitoring), and the
handling of the incident from when the patient was discovered to physician/
family notification and follow-up care.
In the testimony of the plaintiff's nursing expert, the statement was made
that it was the nurse's duty to "ensure" the patient safety. It was only a
single statement taken out of her testimony. None the less, the court focused
on this single point and decided on the basis of it to dismiss the charges.
The rationale given was that the plaintiff's argument was that the nurse was
responsible for "ensuring" the safety of the patient. This statement was
taken literally by the court.
With this clearly being an outrageous standard, the court granted summary
judgement for the defense. It added that in no law available on the books
was a healthcare provider defined as one who made guarantees or formally
"insured" a specific patient outcome. It paid little regard to the remainder
of the nursing expert's testimony in which the applicable standards of care
were outlined.
The plaintiff would appeal:
Questions to be answered:
1. Were reasonable precautions taken in the care of the deceased to
prevent a fall and otherwise provide for a safe environment.
2. Were the standards defined by expert nursing testimony adequate to
compose a credible argument against the
hospital nursing staff in their
care of the deceased.
3. Was the initial court ruling in error when it based it decision on not
the general testimony but only specific portions.
When the appeals court reviewed the evidence presented, it decided that
there was in fact, sufficient evidence to justify a court trial on the issue.
It would state that the lower court was in error in that it made a decision
based on some rather than all of the testimony presented. It is unfortunate
but true that lawyers and judges like physicians and nurses sometimes
will narrowly focus in on specific facts, to the exclusion of others.
For the nurses involved in this case, it makes an excellent point that even
if a case is dismissed initially, it can be re-opened on appeal by either the
plaintiff or defense. Initial cases and appeals can take years to proceed.
Will a nurse have any idea of the facts and particulars of an event that
happened one to two, or even five years ago? Chances are practically
nonexistent that one will be able to recall details. It is for this reason that
daily charting must be complete and thorough. When a fall or an accident
or a mishap occurs, you must be particularly detailed in your documentation.
Your nurses notes form the medical and legal foundation of care that you
gave. When your performance is questioned or criticized in court or before
a state board of nursing, what is written in the chart is typically all you have
to stand on. It will typically be held in much higher regard than hearsay and
testimony based on "memory."
Related Cases:
May 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.htm
Related Link Sections:
Abdominal Aortic Aneurysm, Direct (Bedside Nursing) Patient Care Links
http://www.nursefriendly.com/nursing/directpatientcare/vascular/abdominal.aortic.aneurysm.htm
Clinical Charting and Documentation, Nurses Notes
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm
Courtroom Directory:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms.online.htm
Direct Patient Care Links
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm
Emergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.html
Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm
Falls, Injuries & Prevention, Direct (Bedside Nursing) Patient Care Links
http://www.nursefriendly.com/nursing/directpatientcare/falls.injuries.prevention.htm
Head Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htm
Informed Consent:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.consent.medical.legal.htm
Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.restraints.htm
Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm
Nurse Practice Acts
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/nurse.practice.acts.htm
Operating Room (Surgical) Links
http://www.nursefriendly.com/nursing/directory/spec/operatingroom.htm
Surgical Intensive Care Unit (SICU) Nursing Departments & Specialities
http://www.nursefriendly.com/nursing/directory/spec/surgical.intensive.care.unit.sicu.htm
Sources:
1. 36 RRNL 8 (January 1996)
2. A. S. Coulson, MD. No date given. An Inside Look At Aortic Aneurysms. Retrieved August 1, 1999 from the World Wide Web: http://www.inreach.com/dameron_heart/inside.htm
3. RN+ Systems. No date given. Factors Hospitals Should Consider For Effective Fall Prevention. Retrieved from the World Wide Web July 31, 1999: http://www.rnplus.com/tips.prob.opport.html
4. Haertlein, Carol. No date given. Falls In the Elderly Population. Wisconsin Geriatric Education Center. Retrieved July 31, 1999 from the World Wide Web: http://www.mu.edu/wgec/news/982/falls.htm
http://www.nursefriendly.com/nursing/clinical.cases/072599.htm
