Legal Review and Commentary - Patient dies after fall from bed with unraised rails
News: After falling from her bed in a nursing home several times over the course of six months, a final fall led to a patient’s death. Her son sued the nursing home, alleging a failure to raise his mother’s bed rails. The facility settled for an undisclosed amount of money prior to trial.
Background: The plaintiff placed his 89-year-old mother in a nursing home once she was no longer able to take care of herself due to age and agitated dementia. She was not an easy patient to care for; she complained and was unpleasant to the staff. She had been a patient for about a year when she began a series of falls from her bed.
The last two of her four falls occurred in January 1999, when her bed rails allegedly were left down. The patient often complained that the bed rails impaired her view of the television. Despite the patient’s history of falling, staff heeded her wishes to keep the rails down, partly because doctors had not ordered them to be kept up.
She was found 45 minutes after her final fall, on the floor in a pool of blood with a broken hip and a subdural hematoma. She contracted pneumonia and died within days.
The plaintiff contended the nursing home was negligent for failing to seek a bed-rail order from a physician. The plaintiff also maintained that even in the absence of a physician’s order for the bed rails to be raised, the nursing staff should have had the authority to issue and implement an interim order to raise the bed rails pending the monthly review of the nursing orders by the attending physician.
Because most nursing home patients are seen by their physicians monthly, the plaintiff said that if more than a week had passed following a change in the patient’s condition, and the physician’s orders had not accounted for the changes, the nursing staff should have been allowed to raise the bed rails. (The patient’s condition had worsened after she fell several times from the bed.) The plaintiff also claimed that the nursing staff should have at least notified the physician of the fact that the patient had been falling from the bed and recommended that an order mandating raising of the bed rails be issued.
The nursing home maintained that the bed rails might have been up when she fell. The plaintiff claimed that at least two of the nursing home’s staff nurses admitted that the rails were down. The defendant also argued that the staff followed the physician’s orders and that the nurses were not allowed to deviate from those orders.
What this means to you: As in the previous case, this case illustrates several nursing home industry challenges. The case appears to be the result of understaffing, undertraining, and undermanagement.
"Unlike the hospital counterpart, where the nursing-to-patient ratio averages one nurse for every four to seven patients, most nursing homes have one nurse for every 10 to 12 residents," says Susan Lind, corporate risk manager for American Baptist Homes of the West in Pleasonton, CA.
"The balance of patient care falls on allied health professionals such as licensed practical nurses and nurse’s aides," she says. "In light of the fiscal constraints facing the nursing home industry, these allied health workers often receive minimal wages and benefits. As a result, these employees generally do not have very long tenures, particularly in today’s job market, where comparable wages are paid by other industries for more attractive jobs.
"Given the high staff turnover and limited technology, it is difficult to keep nursing home staff trained and educated. Therefore, you may have the greatest fall prevention program ever created, but you may not be able to train employees fast enough to beat the turnover or have the technical capabilities to make the information readily available or accessible," Lind explains.
Another challenge facing nursing homes that may have been a factor in this case is diversity, Lind says, explaining that many of the residents may be of one ethnicity or cultural background, while the work force may be composed of another.
"Training in cultural and ethnic diversity can be of tremendous value for persons working with nursing home residents," Lind says. "With proper training, the staff can gain a better understanding of the clientele with which they work, and while they may or may not receive positive reinforcement from the patients, at least their co-workers and management will be attuned to the challenges and rewards of such training. But again, the problem with turnover makes providing this or any training program for that matter extremely challenging."
Regulatory oversight is strengthened
To address a number of the systemic problems with operating nursing homes, such as understaffing and undertraining, some jurisdictions have strengthened regulatory oversight. In one state, midnight inspections have become the norm. In others, annual surveys are given at shorter irregular intervals without prior notification.
"It is difficult to predict how care for a growing elderly population will evolve, but clearly, enhanced regulations usually result in cost increases," Lind says. "Many nursing home patients are government-sponsored, either through Medicare or Medicaid, and many use their Social Security income to cover private care, and so any regulatory changes that have cost implications will ultimately cost everyone more. However, as indicated in the rise in settlements and judgments, the standard of care is not necessarily being maintained without there being some systemic regulatory changes."
Reference
Confidential case.
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