Hospital Protocol Violations Lead to Fall, Hip Fracture

A local woman was living independently in her own home.  She had worsening respiratory issues in the weeks before  Christmas.  Her daughter and son-in-law were helping out daily but when her breathing became severely compromised the next day, she was taken by ambulance to the hospital. She had shortness of breath, nasal congestion, a cough, and altered consciousness, and was admitted into the intermediate care unit for monitoring.  The primary diagnosis on admission was acute respiratory failure with elevated levels of carbon dioxide, which at the time was thought to be possibly due to exacerbation of chronic obstructive pulmonary disease (COPD).  She was treated with antibiotics, steroids, brochodilators, and continuous oxygen.  Later, the medical records show that the cause of her acute respiratory distress was actually the flu.

After admission, a hospital physician reviewed her medical history and symptoms, noting her history of prior thoracic compression fractures and severe osteoporosis, with current back symptoms.  The ordered physical therapy, occupational therapy, Tylenol, and fentanyl and/or hydrocodone for break through pain.  The woman’s age, her medical condition, and her use of pain medication made her more susceptible to falls and more susceptible to serious injuries if she fell.

Falls in elderly patient populations are a serious problem.  Falls are the leading cause of accidental injury and death for people over the age of 65 and the rates go up for patients who are older.  It is predictable that a older person will have decreased balance, depth perception, and coordination.  It is predictable that older women may be underweight and may have  osteoporosis.  If the older person is ill or in an unfamiliar environment, the risks increase.  If the person is in pain and requires pain medication or has been given a sedative for anxiety or sleep, the risks increase further.  The more tragic fact is that if an older patient falls, there is a stronger likelihood that they will sustain an injury that will lead to their death, or may sustain an injury from which they will never fully recover.

The hospital knew or should have known that the woman was a fall risk, and under accepted hospital procedures, should have implemented fall risk prevention protocols and followed those protocols to ensure that she would be safe.  The woman’s family was trusting the hospital to keep their mother, mother-in-law, and grandmother safe.

This hospital already had other cases of older hospital patients who had fallen, sustained serious injuries, and died shortly thereafter.  In this case, the hospital identified the woman as a fall risk.  “Falls” are listed as one of the “precautions” noted by the hospital physical therapist who evaluated the woman the day after she was admitted.  Then, the next day, an occupational therapist noted:  “Precautions: Fall Risk.”   The day after that, a physician at the hospital saw her and noted that the woman was underweight and “[t]his puts her at high risk for infections falls and fractures and poor wound healing and other complications.”  

Identification that a patient is a fall risk is meaningless unless the fall risk is properly assessed, an appropriate fall risk prevention plan is put in place, and the plan is followed.  If and when the patient’s conditions change, the fall risk has to be re-evaluated and if necessary a new plan needs to be put in place.  Starting on the day after admission, the woman was identified as a high fall risk using the modified John Hopkins Assessment tool.  The factors increasing her risk of falls were her age; the medications she was taking; equipment she required; the fact that she required assistance or supervision when moving, transferring, or walking; her unsteady gait; and her visual or auditory impairments.   A bed rail was put up to prevent her from falling out of bed or getting out of bed without assistance. 

The woman did well with hospital care, and on the third day after her admission discharge planning had already begun.  Hospital staff discussed with the woman’s family plans for either a care facility, or in-home care, which was the family’s preference.  Several days later, she continued to do gentle restorative therapy and limited walking.  By then, she was  “feeling OK” (having little to no acute pain) and she had no shortness of breath; the flu had largely passed. 

A plan was made to discharge the woman on January 5th.  The discharge papers had been prepared and most arrangements made.  Later that day, the hospital said that she would not be discharged then because not all arrangements were in place, but would be discharged a 9 am the following morning. 

After midnight, the hospital gave the woman Ambien, presumably to aid in sleep.  It appears that she had not ever been given Ambien before.  Older people are especially sensitive to Ambien as it can cause dizziness and extreme sleepiness and make it more likely that such patients will fall.  

The following  morning, the day the woman was to be discharged from the hospital to her daughter’s home, she was found on the floor of her room at 5:58 a.m., confused and in a fetal position.  When she was helped back into bed, she had a 10/10 pain in her right leg originating at the hip, and shooting down her leg..

An x-ray of the hip was ordered which showed “osseous demineralization” and a “[c]omminuted fracturing of the intertrochantric region of the proximal right femur.”  One hospital nurse described the woman’s fracture as a “shattered hip.”

The family did not learn about the fall and the broken hip until they showed up to  move her to their home.  They were  met in the hospital lobby, where it was disclosed that, in violation of hospital  protocols, a nurse had left the bed rails down, causing her to fall out of bed as she rolled over.  They did not know how long the woman had been on the ground before any staff found her.

It is clear from a review of the records that the woman was in extreme pain as a result of the fracture.  Morphine was administered at 6:11 a.m., at 9:29 a.m., at 10:05 a.m., at 3:01 p.m., and a lidocaine patch was applied at 7:34 a.m.  The transfer to the daughter’s home should have been relatively simple.  What actually happened was not, and it was hard for the family to watch, as it was extremely painful for the woman.

At her daughter’s home, the woman received care from Visiting Angels.  The records describe her then as  non-ambulatory, bed bound, and requiring their assistance for all activities of daily living.  In the  weeks before her hospital admission, she  was largely self-sufficient, able to communicate with her loved ones, and able to meet her own grooming needs.  Instead of passing peacefully, with a minimum amount of pain, she died in unrelenting pain, within days after the fracture-fall that the hospital failed to prevent.   This hospital system failure case was settled under a confidential agreement.