Nursing home expert witness opines on fall prevention protocols for high risk patients

A nursing home expert witness opines on a senior care case involving an eighty-seven-year-old male patient with a past medical history of chronic obstructive pulmonary disease and prostate cancer. He was a resident at a nursing home and required close monitoring by the nursing staff due to his past medical history of falls. The patient complained of nausea and diarrhea and was taken to ER by the nursing home staff. The patient was diagnosed with gastroenteritis. He was admitted to hospital for intravenous fluids to treat his severe dehydration. It was also noted that the patient was suffering from orthostatic hypotension. On admission the patient was classified as a high fall risk and issued a yellow wrist band by the admitting nurse. The patient fell whilst getting out of bed to use the restroom. The patient’s bed was left in an abnormally high vertical position by a nurse who was adjusting his bed pan. The patient attempted to get out of bed but lost his balance. He fell from the bed which resulted in a severe fracture to his femur. The nursing notes did not show any evidence of fall precaution measures such as multiple side rails, bed alarms, or continuous monitoring despite the patient being classified as a high fall risk on admission. At the time the fall occurred the patient was being treated for the gastroenteritis and recent pneumonia and seemed to be improving greatly before the accident. However, the complications and adverse sequelae from the femur fracture were listed in the forensic patholology report as contributing conditions to his accidental death.

Question(s) For Expert Witness

What fall prevention measures should have been taken to ensure the safety of this patient?

Expert Witness Response

As a supervisor and a nurse in long term care and hospital care, I have dealt with this issue often. Fall risk prevention in the elderly is well documented in the literature, but unfortunately not often followed through on. Many protocols can be put in place but if they aren't followed unfortunately the above results occur. In this case, I see many issues of lack of standards of care for the nursing staff responsible for this patient. Firstly, once the patient was deemed to be at a high risk of falls this information should have been passed on from the admitting staff to the ward staff. There seems to be a breakdown in the communication between them here. Secondly, the bed should have been kept in the lowest position to reduce the amount of trauma the patient would sustain if he or she were to fall. Lastly, other measures should have been implemented in this patient’s room. For example, the bed alarm should have been on at all times, and, if available, half side rails should have been used.The patient should have been placed in a room near the nurses station to allow close monitoring. The nursing staff should have followed the hospital’s protocol for fall prevention. This case leaves questions for the nursing staff in charge of this patient’s care. Where there any anti-skid stockings on the patient? Why wasn't the bed in the low position? Further, I would question why the patient was still so orthostatic and how fluid replacement and orthostasis was being managed in addition to fall prevention.