Nurse Case Study: 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

Medical malpractice claims may be asserted against any healthcare practitioner, including nurses. This case study involves a nurse working in an emergency department (ED).

Indemnity Settlement Payment:  Less than $50,000
(Monetary amounts represent only the payment made on behalf of the insured nurse)

Legal Expenses: Less than $2,000 (Expenses were limited to cover the cost of nurse expert review and successful early resolution of the claim prior to litigation.)

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 historian and 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 in preparation 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.

Risk Management Comments
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. 

The defense nursing expert opined that the nursing assessment completed in the ED correctly identified the patient as a high risk for falls and nursing interventions were implemented to help reduce the likelihood of a fall. However, documentation by the nurse indicated the patient was confused and uncooperative, and despite efforts to prevent a fall, the need for additional monitoring was warranted to minimize the risk of a fall and keep the patient safe.   

A letter of intent to file a lawsuit, sent by the attorney representing the patient, was received by the hospital and the nurse. After an investigation of the incident was completed, including an interview with the nurse and obtaining a nurse expert review, negotiations pursued between the involved parties in the claim. A settlement was reached prior to a lawsuit being filed, with payment on behalf of the nurse being 45 percent of the total settlement. As mandated by state law, the nurse was also reported to the National Practitioner Data Bank (NPDA).  

Risk Management Recommendations:

  • Know the organization's policies and procedures related to clinical practices and documentation.  Unfamiliarity to established policies and protocols is not a defense, especially if a clinician has acknowledged receiving education on such policies and protocols.
  • Maintain thorough, accurate and timely patient assessment and monitoring, which are core nursing functions.
  • For patients assessed as a fall- risk, implement fall prevention interventions in accordance with department protocols.
  • Invoke the chain of command when necessary to focus attention on the patient’s status. Nurses are the patient’s advocate, ensuring that the patient receives appropriate care when needed.
  • Contact the risk management department, or the legal department of your organization regarding patient or practice issues.

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