The 62-year-old female patient came to the Portsmouth Naval Medical Center emergency department on July 10, 2019. She complained of shortness of breath and leg swelling for three weeks which had worsened that morning. Initially, she was admitted to a progressive care floor. There, she started having increased difficulty breathing and a continued slow heart rate. It was then decided that she would be best served if transferred to the ICU.
The ICU nursing staff note that the patient had an increased risk of falling and appropriately assessed that risk as high. She was also documented as being dizzy, had an impaired gait, and needed a rolling walker when she was up with physical therapy.
On July 11, 2019, at about 2:41 PM, it was documented that the nurse heard a thump and noted that the patient had had an unwitnessed fall. She complained that she hit her head at the time of the fall. She was placed back in the bed and at that time the bed alarm was activated. Neither the bed nor chair alarms had been activated at the time of her fall. A short time later, she was transported to the CT scanner and the CT scan was negative for an acute head bleed.
At around 9:30 PM, approximately seven hours after the fall, the nurse documented that the patient was having nausea and emesis. According to the nurse’s notes, she was evaluated by the resident. No new orders were made. At about 1:30 AM, the nursing notes reflect that the patient still reported nausea, headache, and now had blurred vision in her left eye. A physician was again informed but one did not come to her bedside and examine her. She was simply prescribed oral Lorazepam for the nausea. At about 3:00 AM, the patient was noted to have a decreased level of consciousness, arousing only to painful stimuli. The physician was advised, but the nurse did not document that the physician was requested to come to the bedside, and it does not appear that any physician did so. There were no new orders. Then about 3:30 AM, the patient was documented as being unresponsive with a Glasgow Coma Scale score of 3 and had emesis that required suctioning. The physician was once again notified of the changes without any new orders.
A physician finally examined this unfortunate patient at around 4:00 AM and she was sent for an emergent CT scan of her head. That CT scan demonstrated a large left subdural hematoma. Neurosurgery was consulted and soon after that she was taken to the operating room for a decompression. Unfortunately, surgery was not able to reverse the damage that was done.
The basis for liability was two-fold: First, this patient was a known high fall risk, yet she was left in a chair unattended with the alarm off. She fell. Hospital falls are considered “never events,” as in they should never happen.
Second, after the fall, the Portsmouth staff appropriately got a CT scan. It was negative, but even with a negative CT scan immediately following, the patient’s neurologic status still needs to be monitored carefully as it is well-known that intracranial bleeds can still develop – exactly what happened here. When there were complaints of nausea and vomiting at 9:30 PM, reasonable providers should have been immediately suspicious of a bleed. They were not, as was also the case after midnight, when it was even more obvious. Had a CT been done promptly, it would have shown the bleed and prompt surgery would have likely been successful, meaning the patient would have recovered to her baseline condition.
The patient suffered a devastating and permanent injury. The life care plan estimated the expenses of care at over $2,700,000. The patient’s quality of life was severely diminished. She is now confined to a nursing home, where it is expected she will remain for the rest of her life.