Patient dies from nursing home fall despite documented high risk

A physician friend of mine recently commented on social media that, “I’m old enough to remember when surgeons would take patients to the OR [operating room] for appys [appendix removal surgery] or cholecystitis [gallbladder inflammation] based on the physical exam and history. I still love those old school surgeons.”

Her comment got me thinking about how old school medical care is different than what’s touted as improved care today. Some hospitals and facilities create systems that try and force physicians, physician assistants, nurse practitioners, and nurses to serve metrics and computers rather than the patients they’re supposed to be taking care of.

There’s no doubt that applications, electronics, and screens are addictive for many people.  To prove the point, just look at the nearest table the next time you go out to eat. Some people seem totally unaware of their surroundings while their faces are glued to a device.

Are Healthcare Professionals Balancing Screens and Patient Care?

In healthcare settings, though, there’s often another dimension. Physicians, nurses, and other providers are graded by administrators and bean counters by metrics, meaning how many patients they move through the clinical area in a certain period of time. This creates a mad rush to see the patient, finish documentation, and move onto the next one. In some medical negligence claims that we’ve reviewed, it seems that the medical record documentation was completed with little regard to the patient sitting in front of them. Learn more about how falls during physical therapy can mean medical malpractice.

These thoughts were on my mind while I read a recent opinion out of the San Antonio Court of Appeals. It’s styled Goldwater v. Valdez, No. 04-22-00176-CV.

Josefina was a patient admitted to a nursing and rehabilitation center after she had been hospitalized for acute aspiration pneumonia. During her admission, she fell and hit her head. She wasn’t immediately sent to a hospital for evaluation. That lone is odd.

Did Delayed Evaluation Contribute to Josefina’s Outcome?

Three days after her fall, a physician ordered her to be sent to a hospital emergency room (ER) for evaluation because Josefina was having a nosebleed. About a week later, she was discharged back to the nursing home and was later found unresponsive and then pronounced dead.

Could Proper Care Have Prevented Josefina’s Tragic Outcome?

Josefina’s family filed a medical malpractice wrongful death lawsuit, alleging that the nursing home staff should’ve prevented the fall and then provided proper care after it happened.

The plaintiffs’ experts noted that upon admission to the nursing home, the nursing staff noted in the medical record that she had recently been hospitalized for aspiration pneumonia, but also had pre-existing medical conditions, including chronic anticoagulation.

The nursing care plan called for a mechanical lift with two people assisting any time Josefina needed to get out of bed or move around. A fall prevention plan called for full protections and preventative measures. I wrote in a previous article how hospital and nursing home falls can cause broken bones.

The plaintiffs’ experts in the case wrote reports concluding that the nursing staff and attending physician failed to implement fall interventions that were part of the care plan. As a result, Josefina was dropped by a certified nursing assistant (CNA). The fact that Josefina was on blood thinners because of her pre-existing anticoagulation condition placed her at a heightened risk of injury from a fall.

The experts also noted that the providers documented that they immediately saw a hematoma on the left side of Josefina’s forehead and the back of her head after the fall. Despite notifying the physician, there were no orders. The experts concluded Josefina should have been immediately transferred to the hospital for evaluation, and that the delay in treatment led to her eventual death.

This sad case reflects that it’s not enough to document a patient care plan in a computer record. Nurses and physicians have to actually render the care that’s needed for patient safety and recovery. I wonder if these nurses and physicians were racing to meet their metrics and numbers and in the process literally dropped their patient.

Seeking Justice for Medical Malpractice in Texas

If you’ve been seriously injured because of poor hospital, facility, physician, or nursing care in Texas, contact a top-rated, experienced Texas medical malpractice lawyer for a free consultation about your potential case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.