High Fall Risk Patient Dies After Being Left Unattended For Hours in Hospital

Michael Morgenstern

Written by
— Updated on January 10, 2022

fall risk patientPatient was a known fall risk. While in a Utah-based hospital for irregular heartbeat and in the cardiac care unit the patient was removed from his telemetry and oxygen and left in the bathroom for four-hours during which time he died. Department of Health ruled that a compliance violation had occurred. The decedent’s family retained a Director of Nursing with supervisory nursing care experience on a cardiac floor to provide a better understanding of nursing protocols.

Question(s) For Expert Witness

  • 1. Do you oversee the nursing staff on the cardiac floor of your hospital?
  • 2. Have you ever had a patient develop this outcome?
  • 3. What measures should be in place to prevent this from occurring?

Expert Witness Response

I oversee the planning and day-to-day activities of a 40 bed Cardiac unit with a total of 100 Central Telemetry Monitors with responsibility for a clinical staff of more than 75+, encompassing RNs, PCTs Telemetry Technicians, and Secretaries. I have never had a patient develop this outcome. Patients such as this one should not be left unmonitored or unsupervised to avoid this type of thing from happening. I have reviewed a similar case in the past. This case is within my expertise and I would be happy to review.

Over the years I have supervised a variety of staff, all of which were on cardiac/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. All patients are monitored 24/7 on telemetry/cardiac monitoring. Previously I oversaw a staff of 8-10 RN’s working 12 hours shifts on a progressive care (ICU stepdown unit) cardiac unit housing 24-28 patients needing round the clock cardiac monitoring. Many of these patients were fresh out of angioplasty/PCI following a heart attack where they had stents placed or balloons were utilized to open vessels that led to the attack. This population depends greatly on close monitoring following these procedures to ensure new injury or re-occlusion does not occur. Familiarity with telemetry, cardiac rhythms and general cardiac care is a must to manage a variety of conditions and potentially lethal outcomes. This particular unit monitored the telemetry/rhythms for the entire university system in the area in excess of 100 patients at any one time. Protocols and evidence-based practices are critical in guiding our practice, particularly with respect to the cardiac population needing constant ECG monitoring. I have previous case review experience regarding cardiac patients and monitoring standards that were suspected of having been violated or neglected leading to adverse outcomes due to possible negligence. 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.

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