Director of Nursing Opines on Inadequate Fall Prevention Protocols

Case Overview

This case involves a patient who suffered a fatal fall while under the care of the Defendant hospital. On the date of the incident in question, the patient was under observation in the hospital following a minor stroke and was listed as a known fall risk. Nevertheless, the patient was left unsupervised in his room and taken off of his telemetry and oxygen for over five hours. During this time, the patient had evidently gotten out of bed to use the restroom, where he fell and struck his head on a railing. The patient was found dead by nursing staff several hours later. It was alleged that hospital staff failed to adhere to proper fall prevention protocols, and that the facility was not in compliance with federal regulations governing the same.

Questions to the Nursing expert and their responses

Do you oversee the nursing staff of your hospital?

Over the years I have supervised a variety of staff, all of which were on telemetry units. Currently, I oversee 4-8 RN's on a Cardiac Intensive Care Unit. These cardiac patients are here for a variety of reasons - ranging from heart transplant to post MI (heart attack) care and valve replacement to lethal rhythm (V-tach and Vfib) monitoring and management.

What measures should be in place to prevent this from occurring?

Protocols and evidence-based practices are critical in guiding our practice, particularly with respect to the cardiac population needing constant ECG monitoring. An evidence-based approach to the care of this patient population is critical in protecting patients and the MD's and facilities. System-wide protocols based on a national, research-based set of recommendations are vital to ensuring that current best practices are followed and that harm does not occur to this specific patient population.

About the expert

This qualified nursing expert received a B.S.N. from Georgia Southern University and is currently a BEACON recognized nurse at a top university medical center. He specializes in outpatient and inpatient nursing with a focus on critical care. His responsibilities include all patient assessment and follow-up, AHF & CHF exacerbation, stress testing, angioplasty/stenting, CRRT, IABP, IMPELLA, mechanical ventilation, cardiac ablations/cardioversions, ICU stepdown from surgery, pacer implantation, and more. He is a member of the American Association of Critical-Care Nurses. He is currently a Cardiac Nurse at a major medical center.

E-008244

Specialties:

Nursing