Lots of bad things can happen to patients in the hospital. These complications and events occur so frequently, in fact, that the healthcare industry has come up with a special name for them—iatrogenic injuries, meaning hospital-or healthcare-acquired injuries.
As an Houston, Texas medical malpractice attorneys, one of our jobs responsibilities is to distinguish between complications that were unavoidable even with good care, as opposed to problems caused by medical mistakes or negligence.
In the medical negligence category, there’s one subtype of healthcare mistakes that receives special attention. They are called sentinel events, or never events.
The organizations, such as The Joint Commission, that accredit hospitals and other facilities make lists of sentinel events each year. Healthcare mistakes make their way onto these lists when they are common, well understood, and avoidable with proper care, attention, and policies and procedures.
The Joint Commission requires accredited hospitals and facilities to report each sentinel event that occurs. Plus, they’re required to conduct a root cause analysis to determine why the never event happened and how lessons can be learned to prevent the same problem from occurring again in the future.
One of the Top 10 sentinel events each year for at least the past decade has been patients fall with serious injury. There are hundreds of thousands of falls every year in American hospitals, with about half of them causing some sort of injury to the patient.
So, why is it that patient falls with serious injuries continue to happen even though they are negative events? An analysis of sentinel death reports suggests several key reasons:
• Hospital or facility nurses and other staff don’t follow policies and procedures for fall prevention
• Nurses and other staff members aren’t properly oriented and trained
• In adequate staffing (not enough nurses and staff members to take care of the patient volume)
• Nurses don’t perform an adequate assessment of each patient’s fall risk upon admission, and/or don’t reassess the fall risk daily.
Health insurance bean counters are understandably concerned about how patient falls can add to the length of a hospital admission and add thousands of dollars to healthcare expenses. But the cost to patients in terms of broken bones, pain, suffering, mental anguish, and even death eclipses the dollars and cents.
Fall in a skilled nursing home causes patient death
Sadly, an elderly patient lost his life after a series of falls at Brookhollow Heights Transitional Care Center, LLC. His medical negligence and wrongful death claims were the subject of an opinion recently issued by Houston’s First Court of Appeals, in a case styled Pinnacle Health Facilities XV, LP d/b/a Brookhollow Heights Transitional Care Center, LL v. Deadra Chase et al., No. 01-18-00979-CV (issued July 7, 2020). You can read the opinion here.
The facts of the case are sad to me. The patient was admitted to Pinnacle for skilled nursing and rehabilitation care. He had a variety of age-related conditions including cerebral atherosclerosis (hardening of the arteries to the brain, which can cause visual problems), congestive heart failure, kidney disease, and kidney stones. These kidney conditions, of course, can make a patient feel the urge to urinate more frequently.
Just over a week into his admission, he fell while attempting to go to the bathroom and was found on the floor. The facility staff asked him to use his bedside call button instead of trying to go to the bathroom on his own. A staff member did a full-risk assessment and classified the patient as “high risk” for fall.
Four days later, patient fell again while trying to fold his clothes. A Pinnacle staff member found him on the floor and again asked him to press the call button when he needed help. It turns out that the patient’s call button wasn’t even working and that a repair order had been in place. Apparently, the staff taking care of the patient was unaware of this fact.
Around this time, a staff member ordered bed rails and non-slip mats for fall-prevention. Under the standard of care, nursing and other facility staff have an increased responsibility to take fall precautions for a patient who has a high risk of falling.
Around a month later, another Pinnacle staff member noted that the patient was at a high risk for falls. In his medical record documentation, the references to his medications including diuretics (water pills that cause the need to urinate) and antihypertensives. The staff member also noted that the patient tended to forget his physical limitations and that he needed help to ambulate or walk around.
The next week, staff member found the patient on the floor again. This time, he had a cut on his head. He was transferred to the hospital, where a CT scan showed that he had bleeding on both sides of his brain. Although two weeks of hospital and medical care kept him alive, his condition deteriorated. He needed ventilatory/breathing support and remained unconscious.
His death certificate reflected cause of death of subdural hemorrhage due to blunt-impact head trauma. In other words, he sustained an iatrogenic (healthcare-caused) fall that was so severe that caused brain bleeding.
The plaintiffs in this case believe that the skilled nursing facility violated standard care by poor staffing levels, inexperienced staff, and overall inattention to a patient with high fall risk.
If you or a loved one has been seriously injured because of a hospital, nursing, or rehabilitation facility fall, then contact a skilled, top-rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.