Mr. N, age 79, was admitted to a skilled nursing facility for rehabilitation, assessed as having a high risk of falling.
During the first month of his residency, Mr. N fell nine times, usually when he tried to get out of bed to use the restroom. After each fall, an interdisciplinary team conference was held and interventions were either added or adjusted.
After the sixth fall, padded pants were recommended, but Mr. N refused to wear them. A bedside commode was discontinued because he refused to use it. After the seventh fall, Mr. N was noted to be “confused.” A wheelchair alarm was installed, and he was to be visually monitored around the clock. But his room was not visible from the nurses’ station.
The facility involved the primary care physician, and he declined to recommend any type of restraint. He discussed this with Mr. N and his wife, but these talks were not documented in detail.
One night, Mr. N's bed alarm sounded. Staff reached his room approximately 2 minutes later and found him already using the toilet. While one nurse was shutting off the alarm, the charge nurse stood in the doorway. Nevertheless, Mr. N lost his balance and fell, his ninth fall, hitting his head on the wall. He underwent a craniotomy for a subdural hematoma and later suffered a stroke. He was readmitted to the facility for an expected 3 more months and fell two more times.
Mr. N sued the facility and the facility's management company for elder neglect and violation of the patient's rights. At trial, Mr. N, who suffered severe cognitive loss by this time, was awarded a multimillion dollar verdict, in part, due to the trial court's admitting regulatory citations into evidence. The verdict was reversed on appeal, and a request for review to the California Supreme Court is pending. Mr. N died after the Court of Appeal reversed the jury verdict.
Verify Informed Refusal
In Mr. N's case, better documentation and attention to his plan might have significantly reduced the facility's liability. Documentation of informed consent is the current darling of long–term care, at least in some jurisdictions. However, documentation of informed refusal is just as important, especially in an ambulatory, alert resident. In this case, a jury found conflicting evidence of whether restraints were discussed with either Mr. N or his family. There was also conflicting evidence as to whether or not Mr. N or the family refused restraints.
The facility had a form available for a resident to refuse restraints. However, it simply did not use it. This failure (even though restraints were inappropriate) was probably the key to the jury awarding significant damages.
It is significant that the physician attending to Mr. N did not order them. Unfortunately, this was not documented in detail. Clear documentation by the physician of the impropriety of restraints would have foreclosed the plaintiff attorney's main argument for liability.
According to the Centers for Disease Control and Prevention (CDC), use of physical restraints does not lower the risk of falls or fall injuries and should not be used as a fall prevention strategy. Some researchers have found that restraints “can actually increase the risk of fall–related injuries and deaths,” according to the CDC.
Appropriate and accurate assessment of a patient's fall risk is a critical step to preventing falls. Besides the mandatory Minimum Data Set assessment of each resident, facilities should perform an initial “quick” assessment of each resident's fall risk. This snapshot assessment should note a history of falls; cognition, including fluctuating mental status; impulsivity; vision; ambulation; continence; use of high–risk medications (e.g., antihypertensives, diuretics, narcotics, sedatives, and hypoglycemics); use of assistive devices for transfer or ambulation; attached equipment (e.g., catheters, intravenous lines, and oxygen); familiarity with the environment.
Use this (or a similar) initial risk assessment to create a fall–prevention care plan for each resident. Then review and possibly revise the plan at least every 3 months or after any fall. From an attorney's perspective, all too often care plans are created and then ignored.
After Mr. N's first fall, the facility assessed him and found him to have poor safety awareness and an unsteady gait. Also noted were his attempts to function beyond his ability, including when he repeatedly climbed out of his bed or chair. The facility's interdisciplinary team recommended placing his bed in the lowest position, implementing a toileting program, and regularly reviewing his drug regimen.
Ideally, the care plan would have been updated and the interventions implemented and documented in a way that reflected not only the revised plan, but also nurses’ progress notes, team notes, relevant pharmacist communications, and physician's notes.
The medical chart also should have reflected discussions that facility staff had with the resident, when alert, and Mr. N's representative. Other family communications should have been detailed. Too often such notes say something like “family made aware,” which does not communicate to the end reader (usually an attorney) what was advised and whether or not the family agreed.
After Mr. N's sixth fall, he was not moved to a room that was visible from the nurses’ station. Although making the common sense move to a room by the nurses’ station would not have guaranteed immunity from liability, it would have shown that the facility was being proactive in Mr. N's care.
CDC recommendations include:
Assessing patients after a fall to identify and address risk factors and underlying medical conditions.
Educating staff about fall risk factors and prevention strategies.
Reviewing prescribed medicines to assess their potential risks and benefits and to minimize use.
Making changes in the nursing home environment to make it easier for residents to move around safely. Such changes include putting in grab bars, adding raised toilet seats, lowering bed heights, and installing handrails in the hallways.
Providing patients with hip pads (although evidence for this is weak).
Providing exercise programs that can improve balance, strength, walking ability, and physical functioning among nursing home residents.
Perhaps, providing vitamin D supplementation.
Teaching residents behavioral strategies to avoid hazardous situations.
Accurate assessment, documentation, and follow–up are keys to preventing falls. Common sense is also important: Keep the family informed. If they refuse medical recommendations on behalf of a resident, document this multiple times in the medical chart. Report changes of condition to the resident's attending physician and update care plans as necessary.
Of course, it is impossible to prevent all falls of ambulatory residents, but they can be minimized. Most important from a physician's perspective is to educate an impaired resident's family that restraints are probably inappropriate and that the patient may fall. Detailed documentation of these conversations is important to establish that the health care team is doing what it can to address the patient's risk of falling.
© 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.