Hospital System Failure Causes Death

People with cognitive or physical limitations sometimes need to go to hospitals to obtain medical care.  Hospitals have an obligation to keep these vulnerable patients reasonably safe.  Hospitals must have a program in place to prevent the unnecessary harm that results from patient falls.  If hospitals do not have a good safety program, do not train their employees in such a program, and do not apply the program based on the individual needs of patients, it is foreseeable that patients will be injured and may sometimes die.  Further, if a patient is injured while at the hospital, it is the hospital’s obligation to provide medical interventions necessary to treat that injury.

Unnecessary Fall Injury

In this case, the hospital failed to protect its patient from injury and failed to appropriately treat him once injured, resulting in his agonizing death.  

During the early morning hours, a man was brought to the hospital for chest pain and shortness of breath.  He had a long-standing history of dementia, gait disturbance, confusion,  and falls.  At home, his bed was placed on the floor to reduce the risk of falls.  His wife called an ambulance because of the man’s chest pain, but by the time it arrived, he was already feeling better.  He laughed and joked with the paramedics, who noted that he was in no obvious distress, but he had a low oxygen saturation.  When he was admitted to the hospital, his chest pain had resolved. 

The man’s family told the medical staff at the hospital that he was a fall risk and expressed concerns about his safety.  He was assessed as a fall risk, and was on “stand by assistance.”  His family was willing to spend the night in the hospital to ensure his safety but were told by the hospital to go home and that the hospital would keep watch over him.  After receiving these reassurances, his wife and one of his children left the hospital, returned home, and went to sleep.

Shortly before midnight on that first night, the man got out of bed, stood up, walked toward the bathroom, and fell.  As a result of the fall, he sustained multiple cerebral hemorrhages, and died six days later.   Experts agreed that the hospital care was substandard, and that its acts and omissions caused the man’s death.  

What Happened at the Hospital

The hospital had been made aware immediately that the man had dementia and that he was at an increased risk for falls.  The hospital emergency department notes record that the man was living at home and that he had dementia. The nurse writes that “he seems pleasantly confused, giggling, alert, and oriented  times 1.”  (A person should be oriented “times 3″). 

The emergency department physician could not obtain a history from the man because it was “unobtainable secondary to confusion.”  The man was disoriented.  He was admitted to the hospital with orders to “initiate angina care plan and nursing practice guidelines.”  Upon admission to the hospital, a hospital doctor ordered lorazepam (also known as Ativan)  for anxiety.  The man did not take lorazepam at home.  He was not anxious, and the hospital records do not document any anxiety.  Lorazepam is part of the benzodiazapine class of drugs which increase the risk of falls in the elderly by fifty percent.  

That afternoon, the hospital noted that: (1) the man had a history of falls; (2) that he had cognitive impairment; (3) that his family was concerned about him falling; (4) that he was on medication that increases his risk of falling; (5) that in the nurse’s assessment, the man was at risk for falling; and (6) that the man had short term memory impairment.  The notes mention a fall prevention plan, but there is no documentation about what is involved in that plan, and what was actually implemented.

That night, shortly before midnight, the man presumably sat up, disconnected his pulse oximeter, took off his oxygen cannula, disconnected his IV, disconnected his telemetry monitor, got out of bed, stood up, and started walking toward the bathroom.  A loud crash was heard.  Hospital staff heard the bed alarm, came to the room, and found the man on the floor near the bathroom. 

After the fall, the man was found to be non-responsive, however he was able to open his eyes.    He was returned to his bed using a sling lift.  A CT was taken, which showed a bleed in the right frontal lobe of the brain. 

A hospitalist was brought in to examine the man.  She ordered a STAT CT scan of the brain, which revealed a worsening or expansion of the brain hemorrhage.  The repeat CT showed that the right frontal hemorrhage had gotten bigger, as well as two new areas in the left temporal lobe and the left frontal lobe.

Two days into the hospital admission, the man began acting agitated.  He pushed and hit the staff while they were trying to attend to him.  He pulled out his oxygen tube, and tried to pull out his feeding tube. He was not responsive to directions, and was incoherent.  He seemed to be trying to talk, but his words came out incomprehensibly slurred.  He was medicated and placed in soft restraints.  

The following day, another head CT was taken.  The three areas of brain hemorrhages were seen. and a new of concern was identified, a possible subarachnoid hemorrhage.   That day, a neurosurgeon consulted due to the intracranial hemorrhages, and the fact that the man was becoming more agitated and lethargic.  Another neurosurgeon also evaluated hum, and afterwards explained to the family that it would likely be months before any significant improvement from the hemorrhages could be seen, and that any recovery would be poor.  

The man declined further.  Two days later he developed respiratory distress, which progressed.  He was placed on comfort care measures, and he died hours later. 

Hospital System Failures

The hospital failed to properly care for and protect the man from harm. It was clear that he had cognitive and physical deficits that would contribute to a risk of falling. His  daughter and his wife repeatedly voiced their concern over leaving him at the hospital, but were repeatedly reassured and promised that a bed monitor had been activated, and that he would be safe from harm.  When they finally were able to investigate after the death, no orders were produced by the hospital in the records for either a bed monitor, or siderails.

The man’s assessment on admission reflects deficits that included slurred speech, a history of falls, a history of impaired mobility, and a history of cognitive impairment.  He was confused, his family was concerned about falls, he was not oriented to time or place, he had short term memory impairment, and he was on medications that increased his fall risk.  Despite that, he was placed in an unfamiliar room by himself, the light was turned off, and he was left to his own devices.

The medical records indicate the hospital was negligent in:

– Admitting a fall risk patient with dementia who was not oriented to time or place, without arranging for Protective Care Staffing (a sitter) to stay with him in his room;

– In encouraging family of a fall risk patient to leave the hospital without providing staff support to the patient to prevent a fall;

– Giving an elderly person who was already taking Plavix and aspirin, the drug Keflex, which is known to cause dizziness and weakness;

– Giving the drug lorazepam to a non-aggressive, non-anxious  elderly person who was already taking medications known to cause dizziness,  when the lorazepam was itself known to cause dizziness, weakness, confusion with dementia patients, and lead to fall risks in the elderly;

– Failing to chart any reason why lorazepam, a drug which is listed as not to be given to older patients for treatment of dementia, was ordered, and administered twice to the man on his date of admission;

– Failing to timely respond to a bed alarm in the man’s room by allowing him enough time to sit up, disconnect his pulse oximeter, disconnect his IV tubing, disconnect his oxygen, get out of bed, and start walking to the bathroom before falling; and

– Failing to timely and adequately follow protocol for the diagnosis, evaluation, and treatment of a patient with a known history of traumatically induced brain hemorrhage who was undergoing Plavix and aspirin therapy.

After the man’s fall and after he began bleeding in the brain, the hospital belatedly provided a sitter.  This is what hospital protocol dictated should have been done on admission, before the fall.  If the hospital had ordered and assigned a sitter, he would not have fallen, he would not have sustained multiple cranial hemorrhages, and he would not have died prematurely.  Similarly, if the hospital had not encouraged the family to leave the hospital and provided misleading  reassurances about his safety, he would not have fallen, and he would not have sustained multiple cranial hemorrhages, and he would not have died prematurely.

Placing an elderly person who does not suffer from dementia in an unfamiliar hospital setting is difficult at best.  This patient arrived at the hospital in a pleasant but confused state.   He may have been laughing and smiling, but he was suffering from advanced dementia, and did not comprehend why he was even at the hospital.  He was unable to contribute in any meaningful way to his medical history or examination.  He  was taken to the medical ward,  placed  in an unfamiliar room, given multiple doses of drugs that contribute to fall risks (including lorazepam, even though there was no sign of anxiety, for which it was prescribed).  Then, the hospital staff turned the lights off, and left him on his own. 

What the Man’s Family Lost

The man and his wife had raised eight children.  Before going to the hospital, he woke up each morning, got dressed, cooked some eggs, and made coffee.  Then, he would sit down with his wife and they would eat breakfast, talk, and enjoy each other’s company.  He loved to go places and talk with people, even if they were complete strangers, including the people at Costco who handed out food samples.  He was a genuinely friendly man, with a pleasant upbeat personality, who enjoyed conversation.  He and his wife went out to lunch on a regular basis.  All of his children visited regularly, and one daughter, who lived close by, would come over almost every night, and the family would spend time together talking and laughing.  The couple went to church regularly, and attended “Friendship Sunday.”  At church the man enjoyed talking with the other parishioners.  He had a happy, jovial personality and was quick to joke with and enjoy people’s companionship and conversation.

The man had an additional life expectancy of 5.7 years according to the National Vital Statistics Reports’ actuarial table.  After her husband’s death, the wife’s income was substantially  reduced, due to a reduction in some family and military retirement benefits.

We were eventually able to reach a confidential settlement that addressed both the economic and the human losses to this family.