Nurse Case Study: Alleged failure to properly assess and monitor the impaired, restrained patient

The patient was intoxicated and aggressive when brought to the ED, and had to be restrained. Shortly after an assessment check, the patient attempted to burn off his restraints with a cigarette lighter. He suffered severe burns over 25 percent of his body, resulting in permanent disability.

Indemnity Payment: $0.00
(No payment was made due to the successful defense of the claim.)
Legal Expenses: Greater than $500,000
Note: There were multiple co-defendants in this claim who are not discussed in this scenario. Monetary amounts represent only the payments made on behalf of the nurse. Any amounts paid on behalf of the co-defendants are not available. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited to the actions of the defendant; the nurse.
The patient (plaintiff) was brought to the emergency room where he was well-known to the emergency department staff. He was intoxicated, agitated and aggressive. His behaviors limited the nurse (defendant) and other emergency department staff from completing a comprehensive initial assessment. For the patient’s safety, four point physical restraints were ordered and the defendant nurse requested that security staff apply the restraints per hospital protocol. According to that protocol, the restraint procedure required that security staff also perform a check of the patient’s person for contraband. The defendant nurse assigned the restrained patient to a quiet single room where there would be a less stimulating environment and where he could sleep and calm down sufficiently to undergo a more thorough admission assessment.
The defendant nurse performed patient monitoring and assessment checks every 15 minutes as ordered, missing only one patient check in order to care for a critically ill patient. The missed check, along with the defendant nurse’s monitoring and assessment findings at each of the completed patient checks, were fully documented in the patient’s health information record.
Shortly after the defendant nurse performed a 15-minute check, during which the patient was observed to be resting more comfortably in four-point restraints, the patient attempted to burn off his restraints with a cigarette lighter, igniting his bed linens and clothing. In those few minutes, the patient suffered severe burns over 25 percent of his body including both hands and causing him to lose his fingers on one hand. His injuries required multiple surgeries and he was permanently disabled. The source of the cigarette lighter remains undetermined.
Experts determined that the defendant nurse had acted within her scope of practice and in compliance with both the standard of care and hospital policy. Documentation supported the defendant nurse’s frequent checks of the patient and the reasons for the one missed check, which did not occur at the time of the fire. The fact that the defendant nurse did document the missed check provided additional credibility to her overall documentation. It was determined that the case would be taken to trial.
The case against the defendant nurse was defended successfully at trial, with the jury determining that the patient was responsible for his own injuries. The verdict was appealed on two very narrow legal issues, leading to a second trial and a second successful defense of the defendant nurse and all co-defendants.
Risk Management Comments
The claim took 12 years and two trials to resolve, with total expenses of over $500,000. The patient suffered life changing injuries but they were not as a result of negligence on the part of the defendant nurse. While it might have been less expensive to settle the claim, the defendant nurse’s proper care of the patient and complete documentation of events made an aggressive defense possible and ultimately successful.
Risk Management Recommendations

  • Utilize patient physical restraint pursuant to practitioner orders, when clinically indicated to protect a patient from injury to themselves or others and document the clinical findings that resulted in the application of the restraint.
  • Apply and monitor physical patient restraint as ordered, in accordance with patient needs and in compliance with state regulations, standards of practice and facility policy and protocol.
  • Conduct contraband search in compliance with facility policy to ensure the safety of patients at risk of injuring themselves or others.
  • Maintain restrained patients in a controlled environment to facilitate quiet, calm surroundings for the patient and to prevent contact with non-staff who may introduce contraband or unsafe items to the patient.
  • Perform frequent monitoring and clinical assessment of restrained patients or those who are otherwise deemed unstable and/or at risk for injury to themselves or others in accordance with the patient’s condition, patient care orders, state regulations and facility policies and protocol.
  • Document all patient monitoring, assessment and clinical findings.
  • Document any variation in patient monitoring and assessment protocol and include the assessment findings upon resumption of the monitoring and clinical assessment protocol.

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This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. This publication is published by Affinity Insurance Services, Inc., with headquarters at 1100 Virginia Drive, Ste. 250, Ft. Washington, PA 19034. Phone: (215) 773-4600. All world rights reserved. Reproduction without permission is prohibited.

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