The elements of malpractice were evidenced in an incident that occurred in a skilled nursing facility in 2010. A friend shared her experience in working with a nurse who was responsible for the care of one particular long-term resident who had fallen a number of times. In response to her balance deficit, the nursing staff and attending physician determined that the patient required a ‘lap-buddy’, which is a soft physical restraint, at all times when she was seated in her wheelchair. The patient communicated the need to use the restroom, and the certified nursing assistant was unavailable. The nurse removed the lap buddy and assisted the patient onto the toilet. As the patient was seated on the toilet, the nurse heard a loud call for help in an adjacent room. In the short time that the nurse had run out to make sure that the patient in the other room was well, her patient had slipped off of the toilet. When the nurse returned to the room, she found the patient on the ground wedged between the toilet and the wheelchair. It was apparent that there was no serious injury or fracture because the patient did not complain of pain; however, she presented with a raised, reddened area on the right portion of her forehead that later developed the coloration of a contusion. It is thought that the patient’s head came into direct contact with a part of the wheelchair based on the position in which she was found.
The nurse had a duty, or obligation to ensure the safety of her patient and remain with her patient in the restroom because the soft restraint had been removed. This duty was breached when the nurse left the patient’s room upon hearing another patient yell for help. Because the nurse left the room, the patient with a history of multiple falls did fall from the toilet onto the floor. The patient’s head was injured. The nurse conducted a visual, pain, range of motion, and neurological assessment in addition to monitoring vitals. More specifically, and as per the protocol, the nurse assessed the patient’s status to identify potential signs of drowsiness, nausea, seizures, unequal pupils, headaches, dizziness, numbness, double vision, increased confusion, blind spots, changes in blood pressure or pulse, unequal grip, or unequal extremity movement (Williams, 2006).

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The patient was assisted to her wheelchair after the assessments were performed. The supervisor and physician were notified, and the patient was not sent out to the hospital because no serious injury was evident. The physician instructed the nurse to perform neurologic assessments at specific time intervals to monitor changes in status. “The neurological assessment is a key component in the care of residents with known or suspected head trauma” (Williams, 2006, p. 89). The nurse completed an incident report to document the occurrence. A root cause analysis was not performed because the root cause was obvious – a patient who was at risk of falling was left unrestrained and unattended. The patient was already a member of the ‘Red Star’ program; therefore, no further preventative measures were recommended.

  • Williams, L. (2006). The seriousness of head injuries. Nursing Homes: Long Term Care
    Management, 55(10), 88-89.