Alleged Failure to Recognize and Restrain Patient that Presented Elopement Risk Leads to $900,000 Settlement
Legal Review & Commentary
Alleged Failure to Recognize and Restrain Patient that Presented Elopement Risk Leads to $900,000 Settlement
by: Radha V. Bachman, Esq.
Buchanan Ingersoll & Rooney PC
Tampa, Florida
NEWS: An 88-year-old woman was taken to a local hospital after being found sitting outside her son's home, apparently confused. She was then transferred to a nursing facility, where she was diagnosed with altered levels of consciousness and inability to perform activities of daily living. The woman was again admitted to the hospital and fitted with a vest-restraint system. Based on an interdisciplinary plan of care with regard to the restraints, the woman's vest and wrist restraints were discontinued three days after her admission. The next day, the woman was visited by her son. Soon after her son left, the woman went missing and was found on the hospital roof approximately 14-16 hours after disappearing, dead of hypothermia. The parties settled for $900,000 prior to trial.
BACKGROUND: A woman was found sitting outside of her son's home apparently confused and was taken to a local hospital. After remaining in the hospital for approximately one week, the woman was transferred to a nursing facility, where she remained for two months and was diagnosed with altered levels of consciousness and an inability to perform the activities of daily living. During her stay at the nursing facility, the woman began experiencing an unsteady gait and a continued altered level of consciousness. She was admitted to another local hospital with diagnoses of prior stroke, dementia, and normal pressure hydrocephalus, all causally linked to altered levels of consciousness. A note was entered into the woman's chart that read, "pt. becoming agitated, not wanting to stay in bed." Another notation stated that the patient was an "imminent risk to self" and that she had been found trying to remove the Hep-Lock and attempting to climb out of her bed. In light of these observations, the woman was fitted with a vest-restraint system and moved to a patient room.
A couple of days later, an interdisciplinary plan of care with regard to the restraints was prepared. With respect to the vest restraint and wrist restraints, the plan noted that the woman was "attempting to discontinue therapeutic interventions," as the woman had been found trying to remove the restraints. The defendant alleged that despite the plan of care, the restraints were ultimately removed.
The next day, a physical therapist made a notation on the woman's chart that read, "[patient] sitting in recliner at nursing station due to increased tendency to wander and not tolerating Posey vest." At 10:30 a.m. that same day, an occupational therapist noted that the woman was in her room. Later that day, the woman's son came to visit her for four hours and alleged that the woman recognized him and was able to effectively converse with him. Some time after the visit ended, the woman went missing in the hospital. She was later found dead from hypothermia on the hospital's roof.
The woman's son sued the hospital claiming wrongful death on behalf of his mother's estate. The plaintiff alleged that while his mother was in the hospital, he observed numerous staffers at the facility observing the woman wandering and that none of them took steps to address the elopement/disappearance risk. Furthermore, the plaintiff brought forth evidence that the woman traveled through a fire door without an alarm, through stairs above her room, through a door in the boiler room that should have been locked and through yet another door that should have been locked before reaching the roof, where she ultimately died. Documentation was introduced that confirmed that a mechanical room that the woman traveled through to reach the roof should have been locked, but that the lock had been broken for at least a few months prior to the woman's admission to the facility. Plaintiff's counsel also alleged that the facility had received numerous continuing violations of care-planning regulations, and that an unreasonable number of patient elopements had occurred at the facility in the two years preceding the woman's death. Despite having knowledge of these issues, argued the plaintiff, the facility took no steps to update its policies or provide training or emergency drills.
The defendants denied any wrongdoing, and a settlement was reached between the parties prior to trial in the amount of $900,000.
Reference
Court of Common Pleas of Pennsylvania, Fifth Judicial Circuit, Allegheny County, No. GD-08-026648
WHAT THIS MEANS TO YOU: This case perfectly illustrates several key principles of safety science that help to explain how errors like this occur. In his work on complex systems failure, James Reason posits that every accident is the result of multiple and sometimes seemingly small and unrelated system failures. By themselves, none of these small or latent failures are sufficient to produce a major accident. It is only when the failures aggregate when the holes in Reason's "Swiss Cheese" model line up that serious events with disastrous consequences occur. Such was the case here. This patient's death occurred because of multiple latent failures in two seemingly unrelated systems clinical judgment and routine maintenance. None of these failures by themselves would have resulted in the death of the patient. It was the confluence of these latent defects the failure of the staff to employ adequate clinical judgment in preventing elopement, combined with lapses in routine maintenance that left several doors unalarmed and unlocked that produced the disastrous outcome.
An examination of the clinical judgments made in this case reveals several shortcomings. The decision to apply the vest restraint at the hospital was made after multiple observations by the staff of the patient's altered mental status. Specifically, staff noted that the patient was agitated, was attempting to climb out of bed, was an imminent danger to herself, and had been trying to pull out her Hep-Lock. While this initial decision might have been well-reasoned, it was poorly documented. An interdisciplinary plan of care addressing the use of the vest restraint was not prepared for "a couple of days," and when the plan was finally developed, the staff employed circular reasoning to justify the need for the vest restraint the patient needed the vest restraint because she kept trying to remove the vest restraint. This raises the question of whether the staff had a clear understanding of the patient's risk factors and indications for restraint use, and may have led to the subsequent erroneous decision to discontinue use of the vest restraint without employing alternative methods to ensure the patient's safety.
The day after the vest restraint was discontinued, a physical therapist clearly documented the patient's tendency to wander and also her inability to "tolerate" the vest restraint. This created the duty on the part of the staff to address the potential safety risk of elopement, especially after prior observations that the patient was an imminent danger to herself. The staff initially and appropriately addressed this risk by positioning the patient in a chair near the nurses' station. However, this protective measure was not maintained, and the patient wandered off the unit and to her death later that day. The staff apparently did not consider other alternatives to the vest restraint, which might have included assigning a sitter to the patient.
Also, it appears that the staff did not recognize that the patient's mental state fluctuated during the course of the day. On the day the patient wandered from the unit, a physical therapist noted that the patient had a tendency to wander and that she was positioned in a recliner near the nurses' station. Later that day, the patient's son reported that his mother had recognized him and had conversed with him. While this report from the patient's son may have been reassuring, it did not mean that the patient was no longer an elopement risk. This is particularly true in light of the fact that providers had related the patient's altered mental status to underlying clinical diagnoses of dementia, prior stroke, and normal pressure hydrocephalus. Thus, the staff may have been erroneously reassured by the son's report of the patient's behavior, and as such failed to maintain the proper level of vigilance necessary to prevent her from eloping and harming herself.
An important strategy in guarding against complex systems failure is the implementation of critical redundancies layers of safety strategies that guard against each other's failure. Interestingly, the hospital had a system of critical redundancy in place two locked doors and one door with an alarm but failure to properly maintain the doors defeated this important safety measure.
The many failures of the maintenance system illustrate yet another important safety principle normalization of deviance. This is a phenomenon whereby system failures that go unaddressed over a period of time are no longer seen as deviations and become the organizational norm. Information developed by the plaintiff in this case showed that the lock on one of the doors had been broken for several months. It is clear that lapses in maintenance had become normalized at this organization it is the way the organization routinely operated.
In addition to highlighting key safety principles, this case illustrates several important safety lessons for healthcare risk managers:
Protective measures for confused, disoriented, or wandering patients must be implemented based on clear evidence of safety risks and may be discontinued only if the safety risks are no longer present or if the measure is being replaced with another, equally effective measure.
Patients who are a danger to themselves because of altered mental status or due to any other cause must be assessed regularly to determine safety measures needed to prevent harm. Transient improvements in mental status must not be interpreted as resolution of the underlying causes of previously observed mental status changes.
Routine maintenance plays a critical role in maintaining a safe environment for patients. Environment-of-care rounds are a critical component of the organization's safety program and should serve as the "canary in the coal mine" when routine maintenance and upkeep is being neglected.
Reference
Reason J. Human Error. Cambridge, UK: Cambridge University Press, 1990.
An 88-year-old woman was taken to a local hospital after being found sitting outside her son's home, apparently confused. She was then transferred to a nursing facility, where she was diagnosed with altered levels of consciousness and inability to perform activities of daily living. The woman was again admitted to the hospital and fitted with a vest-restraint system.Subscribe Now for Access
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