Nursing Home Failure to Follow Fall Prevention Protocol and Failure to Treat Spinal Fracture

 We represented a wonderful woman who had moved to the Oregon coast to retire with her husband.  She had a history of back pain and had followed the recommendation of her medical providers to receive conservative, non-invasive treatment for pain.   When that did not provide adequate relief, she was referred to a spine surgeon who scheduled her for two spine surgeries, staged four days apart.  After the surgery, she was given a Thoraco-Lumbo-Sacral-Orthosis (“TLSO”) brace, which is commonly used to support and immobilize the spine after surgery.

To safely and successfully transition her back to living at home with her husband, the spine surgeon determined that she should first stay in a skilled nursing and rehabilitation facility before she returned home.  The surgeon felt that such a facility could provide her skilled rehabilitation therapy and essential assistance in her daily needs such as transferring to and from bed, feeding, toileting, and bathing – none of which she could perform on her own shortly after the surgeries.  Such skilled nursing assistance was necessary not only to help her meet her daily needs but also to prevent injury during her fragile post-surgical condition

After surgery the retiree, then under the influence of significant medication, was placed in her TLSO brace, put on a stretcher, and taken by medical transport to a Eugene area skilled nursing facility.  In response to instructions the facility received for her arrival, the facility began to prepare an Admission Care Plan to outline the specific level and type of care that the employees at the facility must provide to the incoming resident.  The part of the Plan that was completed on the first day of her arrival specified that two persons must assist her for her activities of daily living and for all transfers, such as from the bed to the toilet or vice versa.  The complete care plan also recognized that she posed an additional fall risk due to her confusion induced by her pain medication.  On that first day, the facility also posted an instruction at the head of her bed that read “back brace on when up out of bed” to inform caregivers that they must put the TLSO brace on the woman during transfers. 

On her first night at the facility, she was in a confused state from her medications and asked a certified nursing assistant (CNA) to help her use the bathroom.  The facility CNA did not put the TLSO brace on her, even though it was in immediate reach and the instruction posted at the head of the bed explicitly required  “back brace on when up out of bed.” Without getting the required second person to assist, the CNA lifted her from the bed and walked her to the bathroom without the back brace.  The CNA placed her on the toilet, left her there, and did not return. 

Sometime later, the woman was found in agony on the floor of her room.  It was obvious that she had fallen.  The fall caused her to suffer spinal fractures and spinal cord injury, which require more surgeries and more rehabilitation.  However, the facility did not assess her complaints of pain and did not assess her spine.  It was only after she was transported to another care facility, closer to her coastal home, that it was determined that her spine had been refractured and she had been at the facility untreated for weeks. 

We brought a claim on behalf of the retired woman, which did not settle before trial.   The case settled after the first day of trial.