Question

An 80 year-old male was transported by ambulance to the emergency department (ED) for evaluation after experiencing an unwitnessed fall in a local nursing home.The patient resided at the nursing home and had a medical history of severe dementia and osteoporosis.The patient arrived to the ED alone without family or staff from the local nursing home.

Upon arrival to the ED, the patient was triaged by nursing staff. The triage documentation noted the patient’s vital signs were stable, that he was a poor historianand complained of “hurting all over”. After triage was completed, the patient was taken to a bed in the ED treatment area, which was located approximately 20 feet from the nurses’ station, but not in direct view of the station.

The insured registered nurse assigned to the patient documented that the patient was confused, uncooperative and incontinent. The nursing assessment was completed and noted the patient to be an elderly male at risk for falls.Specific interventions were also documented to implement fall interventions, to include side rails up, place call bell within reach of patient, maintain bed in low position, and consider patient placement close to nursing station.


Two hours later, the patient was evaluated by the ED practitioner. The practitioner noted the patient was restless and ordered a sedation medication inpreparation for diagnostic tests which included a CT scan of the head, and imaging studies of the knee, pelvis and ribs. The insured administered the ordered sedative and the tests were completed in the diagnostic imaging department. The patient was returned to his bed in the ED treatment area. The results of the diagnostic tests were reported as negative.


Following the patient’s return to the ED, the nurse assisted the patient to the bathroom, noting that he was able to walk independently, but had an unsteady gait. The nurse left the room after returning the patient to his bed, placing the side rails up and the call bell within reach of the patient.

Thirty minutes later, housekeeping staff found the patient yelling, laying on the floor on his right side, next to the his bed. Staff immediately responded and the patient was assessed by the ED practitioner. Following the department protocol, staff applied a cervical collar to the patient’s neck, placed him on a backboard and then lifted him to a stretcher. The patient complained of pain in his right hip, and his right leg was noted to be shortened and internally rotated. The patient underwent additional diagnostic tests, and the hip x-rays results confirmed a fractured right hip. Following his return from the imaging, the patient was moved to a bed closer to the nursing station.

The patient was later admitted to the hospital from the ED and evaluated by an orthopedic surgeon the following morning. Surgical intervention for the hip fracture was recommended by the surgeon and the patient’s son provided consent for the procedure. The patient underwent an open reduction and internal fixation of his hip fracture.

Post-operatively, the patient developed pneumonia which required antibiotic therapy and lengthened his hospitalization. He was subsequently discharge back to the nursing home. Despite having the diagnosis of dementia, the patient was able to ambulate prior to this hospitalization, but his activity level is now limited to a wheelchair.

The insured nurse caring for the patient was assigned two other patients that needed close monitoring. The nurse informed the nursing supervisor of her concerns about not being able to provide adequate monitoring for this patient. Despite her concerns regarding patient safety was told that no additional staffing was available. All but one required fall interventions were implemented by the insured in accordance with the ED policy. The one exception was not moving the patient closer to the nursing station until after the fall.

Describe the following terms and how the hospital, supervisor and the nurse were legally sued for above incident.

Failure to follow standards of care

Failure to use equipment in a responsible manner

Failure to assess and monitor and failure to communicate

Failure to document

Failure to act as an advocate

Answer 1

Failure to follow standards of care

The assigned nurse was accountable for the patient fall.She should have shifted the patient with high risk of fall, near to nursing station, for close monitoring and to be able to reach for help whenever needed. The standards of care also means we will prevent any further harm or deterioration of patient's condition. And here before admission patient was able to walk independently and now on discharge his activity limited to wheelchair only. This clearly indicates deterioration of condition.

Failure to use equipment in a responsible manner

The call bell is the equipment which could be used by the patient to reach out for help. Also since the gait was unsteady, the nurse should have provided him with a walker for support during walking. But neither was used properly. The failure of equipment use in proper manner resulted in patient fall.

Failure to assess and monitor

The fall risk assessment should be done properly and necessary interventions should be implemented in patient with high fall risk score. This assessment should be done within TAT (turn around time) on admission itself. The failure to assess and monitoring of patient lead to fall.

Failure to communicate

The nurse assisted the patient to washroom and returned him to bed. She also placed the call bell within reach and side rails up but she didn't taught the use of call bell to the patient. She didn't explained the need of side rails in his case. If she didn't communicate with the patient about his high risk of fall from bed and unsteady gait may contribute to it. There fore this failure in communication of information by the nurse to patient lead to fall of the patient.

Failure to document

After any such incident of fall the incident should be always documented. From what, when, how,etc. all the details of the incident should be recorded in the nurses notes by the nurse. Here, failure of documentation has been noted.

Failure to act as an advocate

The nurse advocates for, and strives to protect the health, safety, and rights of the patient. But here the right to information about his risk of fall has been neglected. Failure to act as an advocate is clearly noted.

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