Nurse Case Study: Failure to ensure a safe environment and failure to utilize translator services

Medical malpractice claims may be asserted against any healthcare practitioner, including nurses. This case involves a registered nurse working in an acute care setting.

Summary

The insured RN was assigned the admission of a terminally ill elderly patient with a gastrointestinal (GI) bleed. Upon admission, the initial nursing assessment characterized the patient as a ‘low fall risk’, despite meeting many of the facility’s ‘high fall risk’ criteria. The insured also noted that the patient did not speak English, but the family could translate when needed.

On day two of the admission, the insured nurse was not assigned care responsibilities for the patient. During this time, the family noted a change in the patient’s mental status. The patient’s daughter, the primary caretaker, reported that the patient seemed confused at times. The examples the daughter gave included the patient repeating the same questions throughout the day, as well as forgetting to wait for assistance when walking to the restroom. The admitting provider documented that the patient’s overall condition remained stable. Due to the reported mild confusion, the provider adjusted some of the patient’s medications.

By the third day of the hospital admission, the insured nurse was again assigned care of the patient. The patient’s assessment of being at a low risk of falls remained unchanged despite notations of being confused and attempting to get out of bed unassisted. At the start of his shift, the nurse walked by the patient’s room and noticed the family at the bedside. The nurse decided to delay his initial shift assessment until after the family left.
 
A few hours later, the patient was found by a family member on her hands and knees on the floor next to the hospital bed. The patient told the family member that she needed to go to the restroom and got up without assistance. She did not complain of any pain or hitting her head when the insured nurse evaluated her after the fall. The insured took the patient’s vital signs, assisted her back to bed and administered the scheduled night medications, which included a medication that had a sedative effect.

An hour later, the family notified the insured nurse of the patient’s acute change in mental status. It was at this time that the insured notified the hospitalist of the fall. A CT scan was ordered, indicating a new cerebral hemorrhage. The patient was transferred to a higher acuity hospital for treatment. She was subsequently transferred to a rehabilitation facility where the family decided to discontinue treatment and she died 10 days following the fall.

Shortly after the patient’s death, the family filed a lawsuit against the hospital, the hospitalist and the insured nurse.

The allegations against the insured included:
  • Negligently and carelessly failing to ensure that the patient’s bed alarm was in place and turned on;
  • Negligently and carelessly failing to inform the patient’s family that the bed alarm was turned off only during their visit and that they should notify the insured when the visit was concluded so that the alarm could then be turned back on;
  • Negligently and carelessly failing to closely monitor the visit from the patient’s family so that he, the insured, would be aware when the family departed and could, therefore, ensure that patient was not left in her room alone with the bed alarm turned off;
  • Negligently and carelessly failing to conduct a thorough nursing and neurological assessment of the patient when she was found on the floor of her room;
  • Negligently and carelessly failing to ensure that a physician promptly saw and evaluated the patient after her fall;
  • Negligently and carelessly failing to obtain and utilize available translator services to question the patient and determine that she had in fact struck her head during the fall;
  • Negligently and carelessly failing to recognize the patient’s mental status changes resulting from her fall and promptly report those changes to the responsible physician;
  • Negligently and carelessly failing to conduct and document a nursing neurological assessment after being informed by family members of the patient’s mental status changes; and
  • Negligently and carelessly administered sedating drug following the fall without informing or consulting the responsible physician.
 

Risk Management Comments

The Department of Public Health (DPH) investigation of the patient’s fall determined that the hospital failed to ensure that the patient was in a safe environment and that adequate protocols were implemented and documented to ensure the patient’s safety. 

The DPH report also criticized the insured nurse and other hospital staff regarding many aspects of the patient’s care. Notably, the report criticized the nurse for failing to utilize an interpreter when examining the patient after the fall, for failing to conduct, or document, a neurological assessment following the fall, or a reassessment, after the patient exhibited mental status changes and for failing to recognize the patient’s mental status changes and report them to a physician in a timely manner. 

The report also criticized the hospitalist for failing to evaluate the patient after being informed of the fall. The nurses on duty prior to the insured’s shift were criticized for failing to initially identify the patient as being at risk for falls, and for failing to document the basis for the change in the patient’s risk for falls. The report further noted that the insured received a written reprimand for ignoring the hospital’s policies related to patient fall prevention, use of a qualified interpreter, and for inadequate documentation and nurse assessments.

Defense experts were asked to review this claim and were generally supportive of the nurse’s actions. However, defense counsel opined that the insured would require substantial preparation for his deposition and thought he would be a questionable witness. The defense also believed that the insured nurse held some biases against the patient based upon her ethnicity. Notwithstanding his pleasant demeanor and nursing experience, concerns were raised that he could be perceived as irresponsible by a jury and that his biases could arouse antipathy.

During the initial meeting with defense counsel, the nurse demonstrated limited knowledge of the hospital’s fall prevention policy and its various monitoring requirements for differing fall levels, despite his understanding of the criteria for establishing the fall levels. He indicated that he considered turning on the bed alarm when he first rounded on the patient, but chose not to because he did not wish to interrupt the family’s visit.

Defense experts testified that the CT scan performed after patient’s fall provided compelling evidence that her brain hemorrhage was a result of the fall. The defense experts also raised concerns that the nursing note regarding the fall was not written until approximately seven hours after the patient fell. In addition, the patient’s fall represented the sole documentation entered into the patient healthcare information record by the insured nurse on that evening. 
 

Resolution

A settlement was negotiated on behalf of the insured nurse. Total Incurred: Greater than $135,000.

Note: Expenses represent the payments made solely on behalf of the registered nurse and do not include payments from any co-defendants. Amounts paid on behalf of the multiple co-defendants named in the case are not available.
 

Risk Management Recommendations

The following risk management recommendations, among others, may be adapted to the individual healthcare organization’s environment of care:
  • Ensure that nursing practice is safe, effective, efficient, equitable, timely, and patient-centered (Institute of Medicine, 2001).
  • Serve as the patient’s advocate in ensuring patient safety and the quality of care delivered.
  • Know and comply with your facility’s policies, procedures and protocols.
  • Use appropriate language translation resources to ensure effective communication (Nursing Scope of Standards of Practice, 3rd Ed.).
  • Anticipate patient care problems before they arise.
  • Communicate initial and ongoing findings regarding the patient’s status and response to treatment in a timely and accurate manner.
  • Communicate using appropriate language and behaviors, including the use of medical interpreters and translators in accordance with consumer preferences (Nursing Scope of Standards of Practice, 3rd Ed.).
  • Document the practitioner notification of a change in condition/symptoms/patient concerns and document the practitioner’s response and/or orders.
  • Participate in Diversity and Inclusion training to learn cultural preferences, worldviews, choices and decision-making processes of diverse patients and families.
  • Acknowledge the harm caused by the unconscious bias within healthcare and identify techniques to address such bias and mitigate its effects.
  • Practice with compassion and respect for the inherent dignity, value and unique attributes of all individuals.
 
 
References:
  • American Nurses Association (2015). Nursing Scope and Standards of Practice (3rd Ed.). Silver Spring, MD: ANA.
  • Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001.
  • Madara, J. L. (2020, August). If technology is to improve health equity, it won’t happen by accident. American Medical Association. Retrieved from https://www.ama-assn.org/about/leadership/if-technology-improve-health-equity-it-won-t-happen-accident
 
 
DISCLAIMERS
These are illustrations of actual claims that were managed by the CNA insurance companies.  However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions  of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.
 
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, NSO websites are provided solely for convenience, and Aon, AIS, NSO and NSO disclaims any responsibility with respect to such websites. This information 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.
Topics:

#Case Study #Medical Malpractice #Patient Fall


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