Fall-Risk Patient Negligently Left Alone Resulting in Hip Fracture
The Clayton Case
This case involved hospital staff negligently leaving a patient, who was a known fall risk, unsupervised to dress himself without assistance resulting in an unwitnessed fall. The fall caused the patient to suffer a hip fracture that required surgery to repair and has left him disabled and in constant pain.
Case Details
Fall-Risk Patient Negligently Left Alone Resulting in Hip Fracture
When 53-year-old Mr. Clayton arrived at the Hospital for what should have been a routine outpatient endoscopy procedure with esophageal banding, he had every reason to expect safe, competent medical care. Instead, a series of critical failures in hospital fall prevention protocols would leave him with a devastating hip fracture and permanent mobility limitations.
The problems began even before Mr. Clayton’s procedure started. During his pre-procedure assessment, rather than conducting the required assessment screening, the nurse responsible for evaluating his condition documented “N/A” when she recorded whether Mr. Clayton posed a fall risk. No assessment screening questions were completed, and the fall risk assessment was entirely omitted from her documentation.
Despite this omission in the medical records, at some point prior to the procedure, hospital staff applied a fall alert bracelet and red socks to Mr. Clayton, which are indicators used to communicate that a patient is at risk of falling. However, there was no documentation anywhere in his medical records to support that these safety interventions were implemented or that any staff member had communicated about his fall risk status.
Mr. Clayton’s endoscopy procedure proceeded without incident. He was administered Fentanyl and Propofol for sedation, common medications that can leave patients drowsy and disoriented as they wear off. After the procedure was completed, he was transferred to the post-anesthesia care unit (PACU) for recovery.
The recovery nurse noticed that Mr. Clayton was “drowsy” following his procedure and required more time than usual to wake up from the anesthesia. This should have been a red flag to Mr. Clayton’s providers that he required further supervision and fall prevention measures. However, despite the fall risk bracelet and red socks that were supposedly in place to alert staff to Mr. Clayton’s fall risk, the recovery nurse failed to reassess Mr. Clayton as a fall risk or implement any additional safety interventions.
The post-procedure nurse then documented in Mr. Clayton’s medical records that he had been discharged home via wheelchair with an escort. This documentation was completely false. Mr. Clayton never made it to discharge and was still in the recovery area when he was left alone, unsupervised, while he attempted to get dressed.
It was during this unsupervised time that Mr. Clayton, still affected by the lingering effects of anesthesia and struggling with the drowsiness that the nurse had already observed, fell while trying to dress himself. The fall was unwitnessed because no hospital staff was present to provide the supervision and assistance that his condition clearly required.
Hospital staff ultimately found Mr. Clayton on the floor beside his bed, yelling out in pain. The fall had caused a right comminuted intertrochanteric hip fracture, a serious break in the upper portion of his thighbone that would require surgical intervention. The following day, Mr. Clayton underwent an open reduction and internal fixation (ORIF) procedure to repair the fracture, a surgery that involves inserting metal plates and screws to hold the broken bone fragments together.
Mr. Clayton remained hospitalized for a week before being transferred to a skilled nursing facility. From there, he required ongoing home health care for therapy and pain management. Despite extensive physical therapy, Mr. Clayton continues to experience chronic pain and mobility issues that have permanently altered his quality of life.
Our investigation into this matter revealed a systematic breakdown in patient safety protocols that violated established standards of care in addition to the hospital’s own policies. We analyzed every aspect of Mr. Clayton’s care, uncovering the dangerous inconsistencies between what was documented and what actually occurred.
In litigating this case and preparing it for trial, we conducted extensive discovery and obtained all relevant medical records, hospital policies, and internal communications related to Mr. Clayton’s care. We also deposed multiple healthcare providers involved in his treatment.
We had this case reviewed by a PACU nursing expert with over 35 years of practicing experience in the healthcare field who confirmed that proper fall risk assessment protocols should have identified Mr. Clayton’s vulnerability, particularly given his post-anesthesia state. She authored a report identifying the hospital’s multitude of failures, and she was prepared to testify as such at the time of trial.
Though hospital falls are at times unavoidable, they are also among the most preventable adverse events in healthcare. Yet, this facility failed to implement even basic safety measures for a patient they should have known to require at least that much. The nursing staff’s failure to conduct proper fall risk assessments, provide adequate post-anesthesia monitoring, and ensure appropriate patient supervision represented inexcusable negligence.
The Result
Shortly before trial, the parties reached an agreement to settle the case for a substantial amount.