Falls Continued

We've focused on some of the more general reasons for falling that may not involve a lawsuit, but now we'll begin to look at some of the causes of falls that are usually caused by negligence or a lack of awareness by others. 

For the next couple of weeks we will focus on patients that reside in a skilled nursing setting or an assisted living setting. 

Another story.  This client was admitted to the nursing home after a hospitalization. She was in the nursing home for rehabilitation.  While the staff was admitting the client to the nursing home she attempted several times to climb out of bed, and ambulate.  At that time it was clear that the client was at high risk for falls.  However the nurse left the client alone without any safety precautions in place.  A few hours later the client was found on the floor by the nursing staff. When the client arrived at the hospital it was discovered that she had broken her hip. 

The story is a bit dramatic (and I imagine that's why it has stuck with me), but it clearly outlines the potential for negligence in a skilled nursing or assisted living setting. 

What struck me the most when I reviewed this client's medical record, was that the nursing staff was so clearly aware that the client was at risk for falls yet failed to put ANY preventative measures in place. There were no bed alarms, side rails, or floor mats in place.  There was no close monitoring of the patient.  The fall risk assessment when it was completed showed that the client was at high risk for falls. 

This is pure negligence by the nursing staff.  They failed to do their job.  They did not set out to harm her, but managed to by failing to provide her with safe, adequate, and appropriate care.  This incident left the client permanently bedridden.  

I know its a very brief overview, but if you use a legal nurse consultant you can get this and so much more. 

Abbreviations

Since it's Halloween on Saturday I though we'd focus on an abbreviation that is both "spooky" and a good reminder to drive safe and drive sober.  Call for a ride if you've had too much to drink. This is an abbreviation that NO medical professional wants to use.

DOA

DOA is dead on arrival

You can see why this is an abbreviation that no medical professional wants to use.  It means that there was no chance to save the patient.

Because of the nature of the abbreviation, there are three primary groups of users - police officers, first medical responders (paramedics, EMTs, firefighters), and ER staff. Rarely is the abbreviation used in other areas.

Examples:


When EMS arrived at the scene of the accident pt was unresponsive without a pulse. Pt was cool to the touch and after consultation with physician no other emergency measures were taken. Pt declared DOA.

This is a bit of an extreme example.

Pt arrived with CPR in progress. Rhythm assessed. Pt was determined to be without a heartbeat.  Pt declared DOA.

This is a more likely example because it is uncommon for first responders to arrive in a situation where the patient is clearly deceased upon their arrival.

Before I end today's post and get back to helping attorneys with their complex medical record needs- I want to note one thing. DOA is a declaration.  It's a status- not just an abbreviation used in the middle of the sentence.  If you note in my above examples, its the end of a sentence.

Tuesday October 20, 2015 Falls (Slip and Fall)

This is a favorite story.  I related it the other night at a party. (As seen on CCTV)

A woman was in a big box store shopping with her young child in the cart. She stopped in the middle of the aisle to look at something. She pulled the cart off to one side as many of us do.  This left her small child within reach of a number of bottled hair care products.  The child proceeded to grab one and squeeze it all over the floor while his mother was not looking. The mother and child then went off. I like to think to inform an employee of what had just happened but we don't know. Within a minute- another customer walked by the same aisle, looked down the aisle and saw the spill. He then strode down the side of the aisle without the spill, disappeared off camera momentarily, came back and purposefully walked through the spill. He fell. He attempted to sue the big box store.

The point of this story is that sometimes falls happen, and sometimes the person falling creates a situation where common sense and safety sense seem to have evaporated.

The above story took place in public, but the same thing can happen in a nursing home.  In the nursing home, it is more likely that the person tripped over their own two feet, failed to watch where they were going, or dropped something, and bent to pick it up.

When accidental falls happen in the nursing home, the best way to prove them to be accidental falls short of the CCTV (which is now somewhat available in Illinois), is a consistent story.  This comes from clients who are alert and oriented x3, and when the client and the staff have a consistent story that fails to change when the client moves from the nursing home to the hospital, and from one caregiver to the next.  The thing is that falls happen. Not all falls can be prevented, and sometimes, clients just slip and fall.

In Illinois, cameras are going to go a long way for nursing homes, and for families, in demonstrating what happens. The camera observes what happened before and after the fall. It can see things, like a person looking at a spill, walking by it, and coming back to see a spill. I am watching for with eager anticipation the first court case with these cameras, and how it plays out.  In the mean time, a nurse can help determine if a fall was truly accidental, or if the fall was consistent with negligence and poor safety behavior on the part of the nursing home.

October 19, 2015 Abbreviations

Today we're just going to dive right in.  There isn't a lot to say about this abbreviation except that it's not a common abbreviation. Because this is not a common abbreviation it can be missed by staff and cause follow up appointments to be missed. This is the importance of having a nurse involved in care. 

Next week I'll do the more common abbreviation. 

This week's abbreviation is:

RTC

RTC means return to care.  Its a very straightforward abbreviation that means when the medical staff wants to see the patient again.  

Example:

RTC in one week for VS monitoring. (Return to care in one week for vital sign monitoring). 

RTC PRN (Return to care as needed). 

Tuesday October 13, 2015 Falls Continued (Falls due to Fainting)

Today I thought we'd focus on the first cause of falls.  I won't ever be able to cover all of the various causes of falls that one can have but I can give some insight into some of the biggest causes of falls.

The first cause of falls that we'll explore is syncapol episode (or fainting).

The causes of fainting can be many and varied but the reason we'll focus on today is a sudden change in blood pressure, usually a sudden drop. It is up to a physician to determine the cause. Causes frequently include illness, sudden change in position (called orthostatic hypotension), or even bearing down to use the washroom and stopping. Another reason for fainting is holding your breath.  You won't kill yourself holding your breath but you will pass out, causing you to start breathing again. It's the body's defense mechanism.

A patient who is otherwise healthy may sit up suddenly in the middle of the night needing to go to the washroom, and the sudden change in position (from lying flat to standing up), which isn't so common during the day (as we're not usually changing positions suddenly during the day) causes the blood pressure to drop as the person has moved too fast for the body to compensate for the change in position and the patient faints and falls. In this case you may hear the thud, but it is uncommon for this patient to have or need safety measures prior to or even after the fall.

In my personal experience this particular patient may have no reason for the episode or it may turn out that they have orthostatic hypotension (their blood pressure drops when they change position) and this may just be the first time that anyone is aware of the condition.  After this initial fall, preventative measure should be taken to prevent additional falls if this is the case.

If the reason is illness, or if there is another reason for the fainting episode, the cause needs to be determined before proper precautions can be put in place.

These patients, like those who may just slip and fall- next weeks focus- may not have precautions in place prior to their falls. This is because many times these clients are at lowest risk for falls prior to their incident. Like any fall, it is important to evaluate the whole record and not the specific incident to find out what happened.

It is especially important for attorneys to work with the medical community, a nurse and physician, to help determine if there is negligence in this type of fall.

Monday October 12, 2015 Abbreviations

We've covered some of the more significant abbreviations in the medical world that are not necessarily understood by the non-medical community.  Today I thought we'd discuss one that most of the non-medical community would know but see if I could shed some more light on in.

Lets get to work.

Today's abbreviation is

VS 

VS- Vital Signs

This is one of the most understood by the "lay person" because it is not only discussed in the media, but it appears on medical shows (ER, Scrubs), and it is something that medical personnel discuss with their clients.

Everyone has had their vital signs checked at some point in their life.  Every time that someone goes to their primary care physician, walk in clinic, or ER, their vital signs are taken.

Vital signs include the following five areas of measurement:

1. Blood Pressure- Ideal 120/60
2. Respiratory Rate- I like to see 14 or 16 breaths per minute, but 12 or 20 breaths per minute can be normal for some clients
3. Heart Rate - Normal is considered 60-100
4. Temperature-- 98.6 is ideal
5. Pain - 0 pain is the goal.

6. Sometimes pain isn't assessed and sometimes also pulse oximetry (the amount of oxygen in the blood) is assessed as part of the vital signs  For pulse oximetry 100% is ideal.


Example:

Pt's. VS are 120/60, 14, 82, 98.6, 100% on RA at 9 am . (RA- room air).  In this example the patient's vital signs would be considered normal.

Pt's VS after treatment 150/80, 110, 99.5, 95% pain 8/10. This patient's vital signs would be considered abnormal.  Because the patient received treatment the abnormal vital signs could be a result of the treatment, but the nurse did not indicate what treatment was given.

Wednesday October 7, 2015 Falls Part 2

Last week we talked about what happens after a patient falls and the nurse finds the patient.  This week we're going to deal with the same scenario, but this time unlike last week the patient will not be ok.

The nurse's note reads as follows

Nurse heard patient call out.  Went to check on patient. Patient found lying on the floor.  Patient's left leg clearly shortened and internally rotated. Vital Signs WNL. Patient complaining of pain of 10/10 in left leg.  Patient made comfortable and 911 called. Patient transferred to the hospital via EMS, physician notified.


Again, this note is not ideal, but there are a number of key elements here that make this a very good note.  While the it is still not clear why the client fell, or if they were a fall risk prior to the fall, the nurse did some very important things.

First the nurse noted that the client was injured (left leg clearly shortened and internally rotated). This is a very clear sign of a hip fracture. Likely of the femur area of the joint.  The hip is three bones, and a break like this is the top of the femur.

The second thing this nurse clearly did right is that she called 911.  A fractured bone after a fall is an emergency.  In the hospital assistance would be called for and the patient would be transferred back to bed where the leg would be stabilized. But in the community, the nurse needed to contact emergency services to transfer the patent to the hospital. Because this is a medical emergency the physician has to be notified but not until after 911 has been notified.

Although it says that the patient was made comfortable while waiting for 911 it would be ideal if it said that the patient was made comfortable on the floor, rather the more ambiguous made comfortable.  The reason for this is that a break can be made worse if the bone/extremity that is broken is moved prior to emergency medical services. But at the same time a pillow for the head and a blanket to help prevent shock, and to keep the patient comfortable is a perfectly acceptable treatment while waiting for EMS services.

Next week we'll focus on what an incident report includes.

October 5, 2015 Abbreviations

Today's abbreviation is very common in the medical world and can mean different things depending on the context it is used in.

Today's abbreviation is

WNL 

WNL means within normal limits.

Like a lot of abbreviations in the medical world, the meaning of this depends on the context in which it is used.

The two examples below show the difference in the abbreviation's use.  WNL when the person doing the documentation does not clarify that it is for the patient, means that it applies to what is normal for the population as a whole.

Sometimes the person documenting clarifies that the behavior, range of motion, or something else is WNL for the client or patient, by stating WNL for patient. This is especially important if the person's mobility is concerned. If the person had limited range of motion, it is likely that the documentation would reflect that is is normal for the person but not normal for the population. With skin color, it is normal to say that it is WNL for clients, because not all patients have the same color skin.

Example

ROM WNL (range of motion within normal limits).

Vital signs WNL