Thursday, October 4, 2012

Hospital Falls Are Not Always the #Healthcare Provider’s Fault, Or Are They? #AmandaTrujillo, MSN, RN - #falls #eldercare #strokes #nurseup


Summary: In April of 2005 Mr. William Delk was a patient at Reid Hospital in Indiana when he fell while seated on a rolling commode in the bathroom. Mr. Delk had recently been a victim of a stroke that left him with complete left sided hemiparesis. He had been readmitted with complications associated with the stroke that were described as "a headache and numbness on the left side of his body." (Tammelleo, 2011) According to the case notes William was a rather large man and coupled with the injury from the stroke he was difficult to move. There were usually two to three people recruited to help move him.

It’s your Friday and the shift couldn’t be going any better. You have not just one, but two, nursing students tonight and you’re feeling like Tiger Woods on a good day of golf. All your charting is done, you’ve delegated duties to both students and everything has been on cruise control. There are six patients to attend to tonight and each of the nursing students has three. Your job has been to oversee all the care and double check the charting and medications. For most of us nurses that’s a pretty good deal on a busy medical-surgical unit. It’s the back half of the night and you’re reviewing some charting done by the students while daydreaming about the cruise you will be embarking on with friends for two weeks in less than 24 hours. You almost wish something would come up that would eat up the rest of the shift so you could go home.

Your nurse iPhone rings. It’s one of your students calling to ask for help in getting a patient out of bed and onto a commode. You tell her you’re on your way and groan to yourself because Mr. “I haven’t had a bowel movement in more than 24 hours” wants to get on the commode for what seems to be the hundredth time today. He is fixated. He has also won the call light contest this shift—by miles. You wonder out loud “Why on earth is this guy way back in the corner of the nursing unit?” At 350 pounds, Mr. C (constipated) is a recent victim of a stroke that left him with complete left sided hemiparesis. Also referred to as “hemiplegia,” this term means a “paralysis on one side of the body resulting from stroke and other lesions involving the motor cortex.” (Lewis, Heitkemper, & Dirksen, 2004) Recently released from a stroke rehabilitation unit just one week ago, this proud 78 year old former marine sergeant is used to “having control of everything” according to his spouse. He has returned to the hospital due to a fall at home during which he hit his head and experienced a brief loss of consciousness. You meant to go back and read over some of the progress notes to learn more about his recent stay in the rehab unit but didn’t get around to it. After two previous days caring for him, you have learned enough to know Mr. C is way more active and “needy” when his wife is not at his side.

When you get to the room your two students are poised and ready to get Mr. C out of bed. He is a three person assist due to the hemiparesis so a gait belt is used to help in getting him to stand and pivot onto the commode. One of the students rolls the commode closer to where everyone is positioned and on the count of three he is successfully transferred from the bed to the commode without incident. One of the students rolls the commode over to the bathroom and positions it over the toilet. At this point you feel comfortable leaving your two students with Mr. C so you return to the nursing station to finish looking over the charting. You browse on over to the Disney Cruise Line website and peruse the pictures of the ship and it’s destinations for the millionth time. “This vacation is long overdue” you say to yourself. Its then that frantic calls for help pierce your escape from the confines of the nursing unit, jerking you back to reality. Without a second thought you jump up and head toward the direction the chaos seems to be gathering. Your heart drops to the floor and a wave of nausea briefly washes over you when you realize—the party is in Mr. C’s room.

One of your two nursing students is kneeling beside Mr. C who is lying on his right side and yelling out that his “side hurts.” You ask one of your colleagues to page the lift team immediately and your assessment of Mr. C begins. He tells you that he wanted to adjust himself on the commode to make it more comfortable but realized no one would hear him call for help because the bathroom door was closed. He was unable to reach the call light because the location of it was behind his right shoulder, he couldn’t get his right arm to reach behind him far enough due to an old shoulder injury he sustained in combat years ago, and he didn’t have his glasses to see clearly where it was—he only knew it was there because the student nurse told him it was. While trying to stand and adjust himself the wheels on the commode went backward and Mr. C lost balance and fell onto his right side. He is in pain, but he is also tearful and apologizing to everyone for trying to get up on his own. “It was stupid to do that! It was all my fault!” You sense Mr. C is feeling shame so you reassure him that everything will be ok and that accidents happen to everyone.

The lift team arrives quickly and while they are maneuvering Mr. C for the lift into bed the source of pain becomes known—it’s the right hip. Your stomach squeezes in on itself, the nausea returns, and you feel flushed as you realize without the use of that right hip Mr. C will be back in the rehab unit for another lengthy recovery. The only good news is that Mr. C denies having hit his head and there are no open or obvious injuries. His mental status is intact, he has a blood pressure and a heart rhythm—you can work with this. Despite feeling a small bit of relief, it begins to sink in that you have to notify the charge nurse, write up an incident report, call the physician, notify the spouse of what happened, and chart the incident. This will be the first, and hopefully last, sentinel event of your career. Later, as you are walking off the unit to go home, your mind is spinning—“What could I have done different? What didn’t happen here that should have to protect Mr. C? Will I have to go to court for this? All of a sudden the Disney Cruise isn’t looking so good anymore as you contemplate the fallout from Mr. C’s unfortunate accident and injury while trying to push away the persistent feelings of guilt that you missed something that could have prevented it.

The Real Thing

In April of 2005 Mr. William Delk was a patient at Reid Hospital in Indiana when he fell while seated on a rolling commode in the bathroom. Mr. Delk had recently been a victim of a stroke that left him with complete left sided hemiparesis. He had been readmitted with complications associated with the stroke that were described as “a headache and numbness on the left side of his body.” (Tammelleo, 2011) According to the case notes William was a rather large man and coupled with the injury from the stroke he was difficult to move. There were usually two to three people recruited to help move him. On this day a student nurse had asked another nurse to help her move Mr. Delk onto a rolling commode utilizing a gait belt and a “stand and pivot” maneuver. The patient was successfully transferred without incident and the student nurse was left on her own to roll the commode into the bathroom and help Mr. Delk get situated. The student nurse made sure to reemphasize to the patient that he should use the call light to ask for assistance and told him the call light was located over his right shoulder. She closed the door to the bathroom and on her way out of the patient’s room she closed that door as well. In an effort to make himself more comfortable and relieve some pressure he was feeling from the commode Mr. Delk leaned forward and fell– sustaining injuries that included a fractured left hip. Nurses heard him cry out in pain and found William on the floor of the bathroom. He was quoted as having said “It just happened and it’s no one’s fault.” (Tammelleo, 2011) Mr. and Mrs. Delk would later file suit against Reid Hospital and the Indiana University School of Nursing alleging that negligence on behalf of the student nurse and hospital were the cause of his injuries.

Discussion Questions:

1.Having read this case would you agree that the nurse was not at fault? Why or why not?

2.This case did not make mention of who was overseeing the student nurse’s care of patients. Do you think he/she should share some of the responsibility for this incident? Why or Why Not?

3.Should a patient such as Mr. Delk have been left alone behind two closed doors? Why or Why Not?

4.Do you think that Mr. Delk’s ability or lack of ability to see or reach the pull cord could have been a factor here?

5.Do you think that Mr. Delk’s thought processes after his stroke could have affected his judgment or understanding of instructions in this situation?

6.Having read this case what precautions, if any, would you have taken to prevent Mr. Delk’s fall?

7.Should the student nurse have been reprimanded for this incident? Why or why not? What actions do you think would be most appropriate to address the student nurse’s role in this incident and why?


On February 26, 2010 The Wayne County Superior Court ruled in favor of the nurse and the hospital. Their findings indicated that “evidence does not support the conclusion that the defendants failed to meet the applicable standard of care as charged in the complaint.” Mr. and Mrs. Delk appealed the court’s decision and once again a decision was made in favor of the defendants. Part of the court’s decision was based on the belief that Mr. Delk knew better than to get up on his own, knew the consequences of failing to ask for help, and knew to ask for help via the call light.


While the title of the article indicates that this is a case study exemplifying a nurse not at fault for patient injury I’d like to use it as a classic example of failure to protect a patient from potential harm. In the summary alone I found many details that left me thinking that both the student nurse and the hospital in this case got lucky—very lucky. Stroke rehabilitation patients have some of the highest fall rates and thus a thoughtful assessment, aggressive safety precautions, monitoring, and constant inspection of the patient’s environment are a must. Stroke victims also have a high incidence for hip fractures. One research article reported that the consequences of a hip fracture are far more devastating than the stroke itself: “Individuals with stroke have not only an increased risk for hip fractures but also more severe consequences. After a hip fracture, they are reported to regain independent mobility in only 38% of cases, whereas this finding was true for 69% of the general population. Mortality rates are found to be doubled 3 months after surgically treated fractures in individuals with stroke—10% versus 5% in hip fracture patients without stroke.” (Weerdesteyn, 2008)

Updated research frequently addresses the lack of data when it comes to identifying how cognitive deficits specifically contribute to falls and the different kinds of cognitive deficits (stroke related perceptual deficits) that exist. However, there is consensus that stroke patients often perceive their abilities to be greater than what they are and often forget (sometimes moment to moment) to include that in their thought processes when making judgments about performing tasks, –add to this the potential for impulsivity. A literature review focused on stroke rehabilitation reveals that how we care for stroke victims in the patient care environment largely depends on our nursing judgment and knowledge of the patient and their abilities: “there are many gaps and shortcomings in the evidence base to inform clinical practice. Therefore, for the foreseeable future many clinical decisions will continue to rely on the knowledge and judgment of individual health professionals. Although improvements in management have been noted, research is still needed to clearly define the effect of specific rehabilitation interventions in a routine clinical setting.” (Langhorne, 2011)

Some of you out there may say “Well, I’m not a rehab nurse so this does not apply to me.” To that I say everything we do with stroke patients (whether new or old injury) is part of their ongoing rehabilitation. From helping people to perform routine tasks, to helping them remember instructions we have given them— our intimate knowledge, or our way of “knowing,” should play a very important part in the clinical decisions we make for this population– regardless of why they are readmitted to the hospital. This case made no mention of how recent the stroke was, whether short term or long term memory loss was a factor, or any cognitive/behavioral deficits (impulsivity) associated with the stroke. These are very important factors that should play into our decision making when assessing whether these patients can be left alone for any period of time.

Nurses are the only providers at the bedside 24 hours a day observing and experiencing first- hand what patients are capable of physically and cognitively. Many times we are the ones picking up on subtle details about our patients that doctors or other healthcare providers have not. Therefore it should never be assumed “everyone knows about this deficit already.” This is a good moment to remember the value of reviewing previous history and physicals. Personally, I like to compare notes and see if what I’m assessing is any different—especially with stroke victims. I need to have a baseline to work from for future assessments.

Falls are one of the most common complications of stroke and there are mixed reviews as to the major contributors to these incidents. A literature review published in the Journal of Nursing Scholarship highlights three factors with strong research support: “Balance Impairment, Hemineglect, and self-care deficit.” (Campbell, 2010) Three factors with good research support included: “Cognitive Impairment and Hemiparesis-motor impairment.” While factors with poor research support included: “Medications, urinary incontinence, stroke type, visual field deficit, apraxia, attention deficit, age, gender, stroke location, communication ability, depression, social cognition, impaired visual or hearing acuity, history of falls, postural hypotension, gait impairment, and response time.” (Campbell, 2010) The review emphasized a big need for more research focused on “largely unexplored domains of cognition.”

What we do every day in patient care environments centers on anticipation of needs. Take a moment to review Maslow’s Hierarchy of Needs. (It’s been a staple in my daily care of patients) Safety is identified as one of the domains. In this particular case I could clearly identify the risk involved with caring for Mr. Delk when I read that he required a two to three person assist to stand and pivot, that he had complete left sided hemiparesis resulting from a stroke, and that he had been admitted for complications of the stroke. I also keyed in right away to the fact the patient was placed on a commode that rolls and was left alone on that device with not one, but two doors between him and the hallway. Although the patient was advised to use the pull cord and told where it was located did the student nurse ensure he could indeed access that pull cord with his right arm? Did she ask him to perform a return demonstration? With a patient presenting as high risk as the one above why didn’t a registered nurse remain in the room to supervise the student?

Being vigilant about the safety and well- being of your patients means constantly asking the “what if” question and always anticipating not just those things that could go right, but also scenarios in which the patient could sustain harm. One article reminds nurses that “the stroke recovery trajectory is long and unpredictable.” (Wagner, 2009) I believe cases like this are important in reminding all of us about the importance of maintaining the circular link between Hi-tech, Hi-touch, and Hi-thinking patient care. Get away from your computers, monitors, and other mobile devices. Return to the basics: Assessment, Diagnosis, Planning, Intervention, and Evaluation. Get back to the care plans. (There are several great care plan books on Amazon) Remember, when nurses go to court specific nursing interventions have to be justified—meaning “why did you do what you did for this patient?” “Why didn’t you do A,B,C, or D for this patient?” Care Plans also help you appreciate a bigger, holistic picture—and you may be surprised by the things you discover about your patients…you may even reveal details affecting their health that would otherwise go unnoticed. The smallest details have the potential to make the biggest difference in a good patient outcome or a poor one.

Related Case Studies:

Patient Falls While Ambulating Post-op, Negligence or Medical Malpractice:"One of the most important interventions post-operatively is to get a patient up and walking. It minimizes chances of complications such as DVT, Pneumonia, Pulmonary Emboli and Decubitus Ulcers. In this case, a patient fell while ambulating. It would need to be decided if a case could be made for simple negligence on the part of the staff, or true medical malpractice."
McBee v. HCA Health Services of Tennessee, Inc. 2000 WL 1533000 So.2d – TN


September 4, 2001, Pathologic Fracture, or Patient Injured in Fall:
Summary: The patient in this case had an extensive Oncologic history including multiple metastases and a predisposition to pathological fractures. When the patient fell while transferring a wheelchair, the cause of the broken hip found after the fall was put into question.
****************************************************** September 26, 1999: Nursing Assistants Leave Client Alone, Patient Receives Second Degree Burns During Bath.
Registered and Licensed Practical Nurses frequently delegate responsibilities and tasks to Certified Nursing Assistants and Unlicensed Assistive Personnel. It is clearly recognized that they are responsible for the actions/inactions of those they supervise. In this case, two nursing assistants recognized injuries to a patient while giving a bath. When they failed to notify the nurse of the injuries, they would be reported and lose their certifications.
****************************************************** August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
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.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
****************************************************** July 11, 1999: Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?
Nursing homes are frequently a patient's destination for rehabilitation following surgery. Common conditions fitting this bill include large bone fractures, hip replacements and stroke. Following these acute episodes, the patients are too unstable to go home and not "sick" enough to have their hospital stays reimbursed by insurance companies. The purpose of admission to a nursing home is to help the patient regain lost function, strength and health. In this case, the patient would remain in the Nursing Home till her death of complications.
Lloyd v. County of Du Page, 707 NE.2d 1252 - IL (1999)
****************************************************** June 27, 1999: Elderly Patient Repeatedly Injured In Nursing Home "Accidents." Negligence, Coincidence or Abuse?
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.
Brickey v. Concerned Care of Midwest Ince. 988 S.W. 2d 592 MO (1999)
****************************************************** Works Cited











William Delk and Sandra Delk, Appellants-Plaintiffs, vs. Reid Hospital & Health care Services, Inc., Indiana University School of Nursing, and the Trustees of Indiana University, Appellees-Defendants, 89A04-1003-CT-208 (Wayne Superior Court November 22, 2010). Retrieved August 15, 2012

Campbell, G. &. (2010). An Integrative Review of Factors Associated With Falls During Post-Stroke Rehbilitation. Journal of Nursing Scholarship, 424, 394-404. doi:10.1111/j.1547-5069.2010.01369.x

Langhorne, P. B. (2011). Stroke Rehabilitation. The Lancet, 377, 1693-1702.

Lewis, S. H. (2004). Medical Surgical Nursing (6th ed., Vol. 2). St. Louis: Mosby.

Tammelleo, D. (2011, April 1). Hospital falls are not always hospital’s fault: case on point. (N. L. Report, Producer, & Medical Law Publishing) Retrieved August 16, 2012, from The Free Library by Farlex:’s+fault:+case+on+point:+Delk…-a0255244601

Wagner, L. P. (2009). Falls among community-residing stroke survivors following inpatient reabilitation: a descriptive analysis of longitudinal data. BMC Geriatrics, 9(46), 1-9. doi:10.1186/1471-2318-9-46

Weerdesteyn, V. d. (2008). Falls in individuals with stroke. Journal of Rehabilitation Research and Development, 45(8), 1195-1214. doi:10.1682/JRRD.2007.09.0145

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Hospital Falls Are Not Always the Healthcare Provider’s Fault, Or Are They? by Amanda Trujillo, MSN, RN

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Hospital Falls Are Not Always the Healthcare Provider’s Fault, Or Are They? by Amanda Trujillo, MSN, RN

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