A 70-year-old male presented to the emergency department with complaints of severe low back pain. The patient had a history of morbid obesity (weight: 377 pounds), chronic obstructive pulmonary disease, congestive heart failure, hypertension, and diabetes mellitus.
The emergency physician ordered an MRI, but the hospital’s MRI machine would only accommodate patients up to 350 pounds. A search of area MRI machines revealed none that could accommodate him. Since the patient had no neurological deficits, it was decided to admit the patient and treat him medically.
The admitting physician did not order fall precautions but did order a bedside commode. When admitted to the floor, the patient was assessed as a moderate fall risk due to his size, complaint of back pain, and treatment with narcotic pain medications, but no fall precautions were instituted. This hospital did not have any policies or procedures concerning the care of morbidly obese patients.
The next morning, the patient asked to use the bedside commode. He was assisted out of bed by a nurse and nurse aide without incident. A few minutes later, the patient asked to be placed back in bed. Again, the nurse and nurse aide assisted him in standing. When the patient began to pivot toward the bed, it started rolling away. The nurse instructed the nurse aide to go to the other side of the bed and hold it in place. When the aide was on the other side, the nurse attempted to help the patient back to bed. The patient stated, “I am falling,” and was lowered to the ground by the nurse. The patient’s left foot and ankle were underneath him. The nurse asked if he was injured, and he replied that he was fine. The patient was rolled onto a blanket and lifted back to bed by eight nurses and aides. He again claimed he was not injured.
That evening, the patient complained of left ankle pain for the first time. The nurse examined the ankle and noted extensive bruising and swelling. The physician was notified, and an x-ray was obtained, showing a comminuted fracture of the left distal fibula. An orthopedic consult was obtained, and the patient required surgery for an open reduction and internal fixation. After surgery, he was transferred to a nursing home for rehabilitation.
A few months later, the patient had additional surgery on the ankle, but he remained at the nursing home. He never regained mobility and is bedfast. Prior to the admission to the hospital, he was fully mobile.
The claimant alleged that a failure to ensure safety from falls led to the patient’s fibula fracture and loss of mobility.
The plaintiff claimed that the nursing staff was negligent when assisting the patient out of bed by not taking into consideration that he was morbidly obese, that he had been assessed as a moderate fall risk, and that he was taking several pain medications. The plaintiff alleged that the nurse should have used a mechanical lift (e.g., a Hoyer lift) to move him. If a lift was not available, a minimum of two nurses should have assisted the patient while another held the bed. The plaintiff also claimed that transferring the patient with the assistance of only one nurse was below the standard of care for a morbidly obese patient on pain medications and that this action led directly to the patient’s fall and subsequent poor outcome.
The defense noted that the patient had been fully mobile prior to admission and had been admitted for less than 24 hours. The physician had not written orders for fall precautions. The patient’s lower extremities had been assessed the previous evening with no neurological deficits, and he had been able to move to the commode safely a few minutes earlier.
However, the defense was unable to find an expert that could fully defend the care in this case. One expert stated that the assistance of one nurse would have been within the standard of care had it not been for the combined risk factors of the patient’s morbid obesity and use of pain medications. These two factors should have been taken into consideration, and additional nurses should have assisted in transferring the patient. This case was settled.
Patient safety issues in this case include a lack of staff training and education on how to safely transfer morbidly obese patients and failure to follow fall precautions for a patient identified as a fall risk. The nurse and nurse aide involved in the incident were seasoned and competent employees, but they did not stop to ask for additional help when the need to transfer this patient arose, and neither considered using a mechanical lift or assistive device. With one staff member holding the bed, only one person was available to assist the patient. While in hindsight it seems that good judgment would have dictated obtaining additional help to transfer a morbidly obese patient who had been assessed as a moderate fall risk (13 on a scale of 5 to 30, with moderate range being 9 to 20), both employees were focused on the immediate goal of getting the patient back to bed.
The absence of any hospital policy and procedure on caring for morbidly obese patients, including safe patient handling and mobility standards, was also a factor. Without written policies and procedures, the hospital staff was essentially without guidance on the proper way to care for morbidly obese patients. The absence of such guidance highlighted a perceived lack of proactive action by the hospital to train employees in the best care of the morbidly obese and made this case difficult to defend.
Each year the number of morbidly obese patients admitted to hospitals continues to rise. It is imperative that hospitals provide employees with training and guidance that specifically addresses caring for morbidly obese patients. Hospitals should develop policies and procedures for care of the morbidly obese and invest in equipment that makes caring for them easier and safer. These actions can help reduce avoidable injuries to both patients and staff.
Department of Veterans Affairs, Veterans Health Administration, VISN 8 Patient Safety Center of Inquiry. Bariatric toolkit. www.tampavaref.org/safe-patient-handling/BariatricToolkit.pdf. Revised August 2015.
Class III obese patients: the effect of gait and immobility on patient falls. Pa Patient Saf Advis. 2013 Sep;10(3):96-8. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2013/Sep;10(3)/Pages/96.aspx#bm4.
By Julie M. Brightwell, JD, RN, Director, Healthcare Systems Patient Safety.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.