Allegation
The lawsuit alleged the insured facility failed to provide adequate staffing, care plans, and fall prevention measures for the resident who was at a high risk for falls; an alleged medication error could also have led to a fall.
Case Details
The resident, an 82 YOM (5’9” pre-amputation, 146 lb), had a history of HTN, diabetes, A-fib, end stage renal disease, dialysis, steal syndrome, AV fistula surgery, CAD, stenting, angioplasty, CVA, peripheral vascular disease, MRSA, MSSA, below knee amputations, and amputations of all left fingers and right middle fingertip. He was transferred to the insured facility after a fall that resulted in an acute left intertrochanteric femoral fracture.
At the time of admission to the insured facility, nursing evaluation notes indicated the resident was a fall risk due to a history of falls and the inability to safely ambulate or transfer without assistance. He was evaluated by the attending physician and orders were entered for PT, OT, wound care on left thumb, and medications. Medications included amiodarone 100 mg on Sunday, Tuesday, and Thursday, and 200 mg on Monday, Wednesday, Friday, and Saturday. The order was incorrectly transcribed as 100 mg tid on Sunday, Tuesday, and Thursday.
One week after admission, the resident was transported to an appointment for debridement of his left thumb wound. During transport back to the insured facility, the resident’s wheelchair tipped over in the back of the van, but he denied injury. Three days later, he was dizzy after dialysis and fell again. The following week, the resident leaned backward and fell out of bed. A nurse noted AROM x4, normal VS, and a 1 cm left elbow laceration.
Later that day, the resident was transported to a dialysis appointment; while there, he complained of left shoulder pain and was taken to the ER. X-rays revealed a comminuted left distal clavicle fracture and osteoarthritis. He was given an immobilizer sling and discharged to the insured facility. That evening, a nurse found a skin tear on his right hand; the resident stated he had likely hit his hand on something. Orthopedics continued the use of the sling; a bariatric bed was added to the resident’s care plan.
Over the next two weeks, the resident sustained a right knuckle skin tear and two right forearm tears. Tubigrips were planned for arm protection. One month after admission, the resident’s medications were refilled. A discrepancy was noted between the initial order and the new order. The transcription error was documented, indicating no adverse effects, and the staff was reeducated. Ten days after discovering the medication error, the attending physician discontinued use of amiodarone on Sunday, Tuesday, and Thursday.
In the two weeks following, the resident received treatment for a number of injuries. The list included a left thumb wound, a pressure ulcer attributed to prosthesis friction, new right hand and left thumb wounds requiring care; the list also included a right wrist skin tear caused by his door latch, which was subsequently padded with gauze.
Six weeks after admission to the insured facility, the resident fell out of his wheelchair after falling asleep. He was found on the floor of his room with right facial abrasions and right wrist skin tears. He received glucagon for low blood sugar. His care plan was updated to include Accu-Cheks, naps after meals, and bed after physical therapy and dialysis.
The next day, the resident complained of hip pain. X-rays of right femur, tibia, and fibula were negative for fracture. The day after that, the resident complained of right facial pain and trouble moving his RLE. He also had new skin tears on his forearms of unknown etiology; Geri-Sleeves were planned. Three days after the fall, dialysis was stopped due to RLE pain. A fentanyl patch was ordered. The next day, topical fentanyl was ordered for pain as well as doxycycline for a left thumb infection. The resident refused to get out of bed due to right leg pain. The following day, wound care was ordered for a right arm skin tear. Following dialysis, the resident demanded transfer to the ER because he was in pain.
After a series of tests, the ER physician diagnosed the resident with chronic polyarthralgia. The resident was discharged to the insured facility while awaiting acute rehab. The next day, the insured facility planned discharge to the acute rehab facility. The resident’s left thumb was to be amputated due to ischemic necrosis, exposed bone, and MRSA. He had multiple skin tears from bumping himself. He was admitted to the acute care rehab facility the following week.
Fourteen days after admission to the acute care facility, the resident was discharged back to the insured facility. One week later, he was noted to be chronically ill, lethargic, debilitated, and with poor cognitive status and a clear decline since his original admission. He was transferred to the hospital with nausea and vomiting the same day.
While at the hospital, the resident underwent left arm AV fistula ligation, insertion of a right internal jugular tunneled dialysis catheter, and carpal metacarpal disarticulation. He was readmitted to the insured facility three weeks later. The resident continued to develop skin tears while at the insured facility.
Three weeks after readmission to the insured facility, the resident underwent dialysis catheter replacement at the hospital after his catheter came out when he rolled over in bed. The resident returned to the insured facility and remained there until his wife took him home three weeks later AMA. The insured facility had no other interaction with the resident.
In the three months following his discharge from the insured facility, the resident had a dialysis catheter replaced and continued to have right knee wound care. He was admitted to the hospital for MRSA sepsis, MRSA bacteremia, and septic prepatellar bursitis steal syndrome. He also underwent I&D on three separate occasions and had an above right knee amputation. He was again admitted to the hospital where a CXR identified small bilateral pleural effusions and subsegmental atelectasis. He became increasingly unresponsive; a CT of the brain identified a border zone right MCA infarct, with no large mass effect and no hemorrhage. He was transferred to the ICU with acute mental status changes, and an apparent CVA possibly due to lower BP with dialysis. He died four days later. Aspiration pneumonia was listed as the cause of death.
Expert Testimony
Plaintiff experts alleged the insured facility failed to provide adequate staffing, care plans, and fall prevention measures for the resident who was at a high risk for falls. They also alleged the medication error could have led to a fall.
Defense experts agreed the medication error did not harm the resident. They also agreed the types of fall the resident experienced were not classic nursing home falls and the staff responded appropriately, meeting the standard of care.
Resolution
Due to external factors, including investigations of the insured facility and allegations of misleading marketing, the case was settled with the defendant’s consent.
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