Fall From Beside Commode: Court Finds No Proof Hospital’s Nurses Were Negligent.
Legal Eagle Eye Newsletter for the Nursing Profession
May 2019
The patient’s widow has failed to prove by a preponderance of the evidence that the hospital’s nurses and other staff breached the standard of care. The patient had shown his nurses he was capable of using the bedside commode and his nurses were close by when he suddenly fell off.
The hospital’s nursing expert testified that when a patient is in an embarrassing situation the standard of care for nurses includes recognizing the patient’s dignity and providing an opportunity for the patient to have some privacy and a sense of normalcy.
While he was getting on the commode the nurses conversed with the patient. He did not slur his speech as he had at other times because of his chemotherapy and antibiotic medications. The nurses did not take their hands off the patient until he was seated securely on the bedside commode, but then took their hands off him. Even placing a hand on the patient while the patient is on the commode will not guarantee the patient will not suddenly fall forward as this patient did.
The standard of care required a nurse to stay in the room after helping the patient to get on the bedside commode. Two nurses were present. The nurses had been continually assessing and reassessing the patient’s fall risk and documenting their assessments in his chart before he fell.
UNITED STATES DISTRICT COURT ARKANSAS March 31, 2019An elderly multiple myeloma patient suddenly fell forward to the floor from a seated position on his bedside commode and broke his neck. The two nurses present started CPR and called a code. The patient was intubated and taken to the ICU. Two hours later he was extubated. A CT scan and an MRI later that day revealed an odontoid process fracture in the neck that was compromising the spinal cord and causing paralysis. Spinal surgery was performed successfully after a transfer to a university medical center.
A week after his surgery the patient was discharged home on hospice care. At home he succumbed to his multiple myeloma four weeks after his fall.
After his passing his widow sued the hospital over his fall. The US District Court for the Eastern District of Arkansas found no evidence of nursing negligence related to the fall and dismissed the case.
No one tried to dispute the fact the patient was a high fall risk. Nevertheless the Court took the time to outline in detail how his nursing and medical caregivers performed very thorough ongoing fall-risk assessments that led up to the seemingly routine task of assisting a patient to use a bedside commode. The patient was a military veteran already on 100% disability due to epilepsy, before his myeloma was diagnosed.
Five days before his fall the patient was admitted to the hospital for a fever that came on after a blood transfusion that went with an outpatient chemotherapy session. He and his wife were following the hematologist’s recommendation to go to the emergency room if a fever developed. The first nurse who saw him in the emergency department obtained a Morse Fall Scale score of 65. His admitting nurse scored his fall risk at 70. The hospital’s criteria rate a patient a high fall risk with a score of 45 or higher. The admitting nurse also documented a history of at least one fall at home during the prior twelve months.
Over time in the hospital the nurses began to observe and document periodic episodes of diminished cognition that were likely related to his chemotherapy agents and to the antibiotics he was receiving for the fever that brought him to the hospital. The patient’s wife, a retired RN, alerted the nurses when she was having trouble trying to assist her husband to use his hospital room bathroom. However, when a nurse went to help her husband while he was still in the bath-room the nurse found he was able to stand and walk back to bed on his own.
The widow’s testimony that she had had difficulty on her own assisting her husband to the bathroom was offered to reinforce and amplify the grave fall risk presented by the patient’s condition.
The Court, however, interpreted the widow’s testimony about the difficulty she herself experienced assisting the patient to the bathroom as validation for the nurses’ decision to substitute a bedside commode in place of trips to the bathroom. The commode was apparently kept in the bathroom and wheeled to the beside when the patient notified his caregivers he had the need.
The patient’s widow’s lawsuit alleged specifically that the patient’s nurses were negligent for allowing him to use the bed-side commode, for not having a hand on the patient while he was sitting on the commode and for not standing directly in front of the patient to be able to catch him if he suddenly fell forward. These allegations were carefully considered but rejected by the Court. The Court did not give much credence to certain other allegations in the lawsuit, that the patient should have been restrained and wearing a helmet on the commode and there also should have been a fall pad on the floor, a bed alarm in use and more frequent checks on the patient’s bathroom needs.
Two nurses assisted the patient to the bedside commode. One of the nurses testified when the nurses came to the room the patient sat up in bed without a problem and said he did not feel dizzy and could stand up on his own. The nurse observed that his speech was clear, appropriate and coherent and he did not appear dizzy or weak. The other nurse said basically the same, that when the patient sat up in bed he did not appear lightheaded or confused and did not slur his speech. She asked him if he was ready to stand up and he said he could stand.
The Court credited the testimony of the hospital’s nursing expert that the standard of care for nurses when a patient is in a private situation calls for the nurses not to have their hands on the patient and not to stand closely in front. In this case one of the nurses was right behind or beside the seated patient and the other was in front, two to four feet away, according to the nurses’ testimony. The Court did not believe the widow’s confused and inconsistent testimony that one of the nurses walked away while the patient was on the commode to start setting up an IV.
The Court’s decision to dismiss the case against the hospital was also based on the hospital having appropriate standard nursing protocols in effect for fall-risk assessment and fall prevention, in addition to the fully competent care that was actually provided by the hospital’s nurses. Those measures included having the call bell always within easy reach of the patient, answering call bells promptly, checking frequently with the patient whether he needed to go, having the bed in its lowest position with wheels verified as locked, use of non-slip footwear, having canes, walkers, wheelchairs, etc., easily accessible but keeping the room free of other objects and clutter and having all liquid spills promptly cleaned up.
The key factor in the hospital’s favor was that the nurses determined as best they could that the patient was capable of transferring and sitting on the commode at the very time of this incident, even though that judgment unfortunately proved incorrect in the light of 20/20 hindsight. Nevertheless the Court was impressed with the patient’s chart record of an ongoing effort by the nurses to assess the patient’s changing fall risk, to document their assessments and to pass along their most current information about fall risk to other nurses in nursing shift-change reports. That tended to show a very high level of care and concern that tended to mitigate a finding of negligence.
Howard v. US, 2019 WL 1442219 (E.D. Ark., March 31, 2019).More references from nursinglaw.com
http://www.nursinglaw.com/hospital-fall-nursing-negligence.htm
http://www.nursinglaw.com/fall-getting-out-of-bed.pdf
http://www.nursinglaw.com/fall-negligence-nursing-home.htm
http://www.nursinglaw.com/fall-negligence-outcome.htm